Sexual Assault,Posttraumatic Stress,Alcohol Use,and Suicidality Among Diverse College Students

Abstract

Suicide is the second leading cause of death among college-aged populations. This study examined the association of demographics (sexual orientation, gender identity, age, and race), sexual assault, posttraumatic stress symptoms (PTSS), and alcohol use with suicidality, current urge to self-harm, and current suicidal intent among a diverse sample of college students (n = 2,160) from two universities. Over half of participants reported any suicidality (63.5%), 12% reported current urge to harm themselves, and 5% reported current suicidal intent. A linear regression indicated that participants who identified as a sexual minority, gender minority, consumed more drinks per week, and had more severe PTSS reported higher levels of suicidality. University also was associated with suicidality. A negative binomial regression demonstrated that participants who identified as a sexual minority and had more severe PTSS had more current urge to harm themselves. Further, a negative binomial regression demonstrated that first-generation college students, students with more severe sexual assault histories, and students with more severe PTSS had higher current suicidal intent. Findings suggest that risk factors may differ for college students’ general suicidality, self-harm urges, and suicidal intent, suggesting that these may be separate constructs. More comprehensive models, incorporating multiple risk factors and multiple ways of assessing suicidality, are needed to better understand the range of college student suicidal behavior and risks.

Keywords

alcohol and drugs sexual assault LGBTQ PTSD ethnicity

Suicide among young adults is a significant public health concern and has increased 35% in the past 20 years (Curtin, 2020). Importantly, suicide is the leading cause of death in adults age 15 to 29 (Centers for Disease Control and Prevention, 2018; World Health Organization, 2019; Zhang et al., 2013), and college students display alarming rates of suicide, suicidal ideation (i.e., thinking about or planning suicide), and nonfatal suicide attempts (Li et al., 2020; Uchida & Uchida, 2017). High rates of suicide risk among college students have been attributed to many variables during the college years including high levels of stress, mental health concerns, and significant life changes (Li et al., 2020; Liu C. H. et al., 2019). Myriad factors place some college students at higher risk for suicidal thoughts and behaviors, including exposure to potentially traumatic events, alcohol use, and mental health disorders. Additionally, sociodemographic variables (i.e., gender and race/ethnicity), sexual orientation, and being a first-generation college student are indirectly associated with suicidal thoughts and behaviors. Increased risk for suicidal thoughts and behaviors is potentially due to higher exposure to potentially traumatic events, as well as stress related to experiences of systemic discrimination and experiences of daily discrimination. However, it is unclear what factors are associated with heightened risk for engaging in suicidal behavior among college students.

Demographic factors are associated with an elevated risk of suicidal thoughts and behaviors. These demographic characteristics likely indicate indirect effects, such as specific demographic groups having higher rates of discrimination, poverty, trauma exposure, or factors such as perceived burdensomeness. Men and minority individuals report significantly higher levels of suicidal thoughts and behaviors than women and nonminority individuals (Mackenzie et al., 2011; Zhang et al., 2013). Suicide among Black youth is on the rise faster than any other racial/ethnic group (Congressional Black Caucus Emergency Taskforce on Black Youth Suicide and Mental Health, 2019). Although White youth have higher risk for suicide than Black youth, suicide risk has decreased for White youth while suicide risk among Black youth has increased significantly, with a 73% increase in suicide attempts and 122% increase in injury by attempt in the past 25 years (Lindsey et al., 2019). This increase may be due to a number of factors including race-related trauma and discrimination and lack of access to mental health care (Congressional Black Caucus Emergency Taskforce on Black Youth Suicide and Mental Health, 2019).

Sexual orientation can also impact risk for suicide, as lesbian, gay, bisexual, trans, and queer (LGBTQ) students are at heightened risk for suicide, experience significant health disparities, and are less likely to receive needed care than their cisgender, heterosexual peers (Hafeez et al., 2017). Specifically, results of meta-analytic reviews have indicated that LGBTQ individuals are at least two to three times more likely to attempt suicide than their heterosexual peers (Miranda-Mendizábal et al., 2017), which is likely due to stigmatized identity, victimization, and discrimination (Gnan et al., 2019). Finally, studies have found that first-generation college students may be at higher risk for mental health concerns that are related to higher levels of suicide (Stebleton et al., 2022; Stephenson et al., 2005). Taken together, research suggests that certain demographic characteristics are associated with suicidal thoughts and behavior. However, that is not to say that being a member of these demographic groups is the cause of suicidal thoughts and behavior. Instead, members of these demographic groups tend to experience additional and undue stress due to systemic discrimination, experiences of daily discrimination, and additional hardships. Therefore, it is important to include these demographic characteristics in examinations of factors associated with suicidal thoughts and behavior while also examining other potentially more direct factors associated with suicidal thoughts and behavior such as exposure to potentially traumatic events (i.e., sexual assault), posttraumatic stress symptoms (PTSSs), and alcohol use.

Sexual assault, or nonconsensual sexual activity ranging from sexual contact to penetration, is common on college campuses with 1.8% to 34% of women and 4.8% to 31% of men reporting unwanted sexual contact, 1.8% to 14.2% of women and 1.9% of men reporting incapacitated rape, and 0.5% to 8.4% of women and 0.7% to 7% of men reporting physically forced rape during college (Fedina et al., 2018). Furthermore, LGBTQ college students are at increased risk of experiencing sexual assault in college (Fedina et al., 2018). Among a national sample of women, those with sexual assault histories were more likely to report lifetime suicidal ideation and attempts compared to those without sexual assault histories, even after controlling for posttraumatic stress disorder (PTSD) and alcohol use (Ullman & Brecklin, 2002). Furthermore, a meta-analysis examining psychopathology after sexual assault victimization indicated that sexual assault history was associated with the highest increases in suicide risk compared to other psychopathologies (Dworkin et al., 2017). However, the studies included in the meta-analysis mostly focused on women as victims of sexual assault. Therefore, more work is needed to understand the association between sexual assault and suicidal thoughts and behaviors among a wider range of sexual assault survivors.

In addition to sexual assault, college students have exposure to other traumas that may result in significant PTSS and alcohol use (Barrios et al., 2000; Cherpitel et al., 2004). Exposure to potentially traumatic events (e.g., physical assault, domestic violence, witnessed personal, or community violence), including sexual assault, and PTSS place individuals at risk for suicide, which is particularly important for college students given that 66% of students enter college with a history of exposure to a potentially traumatic event (Read et al., 2011). Rates of suicide among individuals with PTSD have been estimated to be 13 times higher than those without PTSD after adjusting for demographics and psychiatric comorbidities (Gradus, 2018). Importantly, 72% of Black college students have experienced at least one form of trauma in their lifetime (Boyraz et al., 2015). Given that exposure to potentially traumatic events and PTSD are associated with suicidal thoughts and behaviors, and that Black college students experience more exposure to potentially traumatic events, it is important to consider race when examining factors related to suicide among college students.

Alcohol use has long been linked with “deaths of despair” including suicide (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2019) and is associated with up to 73% of completed suicides (Barrios et al., 2000; Cherpitel et al., 2004). Similarly, up to 40% of individuals seeking treatment for alcohol use have a history of suicide attempts (Yuodelis-Flores & Ries, 2015). Although rates of alcohol use are typically highest among individuals who identify as White (Grant et al., 2015), individuals who identify as Black, compared to White, are more likely to experience alcohol-related health problems, which can include higher risk for suicide (Delker et al., 2016). Conferring more risk, LGBTQ individuals, who are a growing population on college campuses, are also at heightened risk for alcohol misuse compared to their cisgender and heterosexual peers (Dermody et al., 2014; Fish et al., 2018; Kerridge et al., 2017; Talley et al., 2016).

Given that sexual assault and alcohol use are common among college populations, the current study examined the association of demographics, sexual assault, PTSS, and alcohol use with suicidality, current urge to self-harm, and current intent to suicide among a diverse sample of college students. Accordingly, it was hypothesized that suicidality, current urge to self-harm, and current suicidal intent will be higher among students with exposure to sexual assault, PTSS, and higher rates of alcohol use. Furthermore, because previous research has found that certain demographics place individuals at additional risk for suicidal thoughts and behavior indirectly, we hypothesized that those who identify as Black, men, and LGBTQ would report higher suicidality, current urge to self-harm, and current suicidal intent. This study will provide a needed next step in examining risk factors associated with suicidality and current suicide risks among college students who are suicidal.

Methods

Participants

Participants were recruited via an email invitation and through college psychology courses to participate in an online survey on alcohol use and social behaviors. Given difficulties in recruiting LGBTQ populations in research, targeted recruitment advertisements were used to recruit LGBTQ students. Participants were eligible for the study if they were between the ages of 18 and 25 and attended the main campuses of two large, public, minority-serving universities in the United States. A total of 2,160 students completed the online survey. Participant demographics are presented in Table 1.

Table 1.

Descriptive Statistics.

Variable Name	N	%	M	SD
Gender identity
Men	660	30.6
Women	1392	64.0
Gender minority	108	5.0
Transmale/transman/FTM	9
Transwoman	1
Genderqueer	18
Gender nonconforming	10
Nonbinary	54
Androgynous	10
Not listed	6
Race/ethnicity
White	910	42.1
Black	433	20.0
Asian	507	23.5
Latine	346	16.0
Multiracial	92	4.3
Other race	110	5.1
Native American/American Indian/Alaska Native/Indigenous	33
Middle Eastern/North African (Non-White)	54
Pacific Islander/Native Hawaiian	11
Not listed	12
Sexual orientation
Straight/heterosexual	1467	67.9
Sexual minority	693	32.1
Lesbian	66
Gay	49
Bisexual	320
Queer	53
Two spirit	1
Questioning	76
Pansexual	79
Asexual	36
Not listed	13
University
1	1023	47.4
2	1137	52.6
First-generation college student	717	33.5^a
Age			20.09	1.58
Suicidality			6.11	3.54
Endorsed any lifetime suicidality	1274	63.5^a
Current urge to self-harm^b			2.68	4.56
Endorsed any current intent to self-harm	201	12.0
Current intent to suicide^b			1.09	0.48
Endorsed any current intent to suicide	84	5.0^a
Average drinks per week			3.65	6.34
Endorsed any drinks	1126	52.1
Sexual assault history severity			14.03	20.87
Endorsed any sexual assault history	1025	47.5
PTSSs			11.59	9.28
Endorsed any PTSSs	1772	15.5^a

Note. PTSSs = posttraumatic stress symptoms; SBQ-R = Suicide Behaviors Questionnaire-Revised.

Missing data so percentage was from valid percent.

Current urge to self-harm and current intent to suicide were only asked among those who scored 3 or higher on lifetime suicidality (SBQ-R), which included 1,429 participants. Therefore, the percentages are based on 1,429 participants for these measures.

Measures

Demographics

Participants completed items assessing age, gender, sexual orientation, race, ethnicity, and first-generation college status.

Suicidality

The Suicide Behaviors Questionnaire-Revised (SBQ-R; Osman et al., 2001) is a four-item survey assessing lifetime suicidal ideation or attempt, frequency of suicidal ideation over the past year, threat of suicide attempt, and likelihood of suicide in the future. Scores range from 3 to 18 and scores of 7 or above indicate suicide risk. Due to a programing error, the item assessing likelihood of suicidal behavior in the future only included six items instead of seven and the scores were adjusted to reflect that error. The SBQ-R score was used as the measure of suicidality. Two single-item questions from the Linehan Risk Assessment and Management Protocol (L-RAMP; Linehan et al., 2012) were assessed among individuals with a score over 3 on the SBQ-R, indicating some suicidal ideation, and asked “On a scale of 1 to 7, what is your urge to harm yourself now?” and “On a scale of 1 to 7, what is your intent to kill yourself right now” with answer options ranging from low (1) to high (7). The item assessing urge to self-harm was used as the measure for current urge to self-harm. The item assessing intent to suicide right now was used as the measure for current suicidal intent.

Sexual Assault Victimization

The Sexual Experiences Survey-Short Form Victimization (SES-SFV; Koss et al., 2007) assessed participants’ victimization of unwanted sexual experiences that occurred at two different timepoints: (1) between age 14 until the past year and (2) during the past year (past 12 months). The score for sexual assault severity was created using both timepoints for the current study. Several categories of sexual victimization were assessed such as sexual contact, coercion, and attempted or completed penetration. One item was revised to be more gender inclusive (i.e., “vagina” was changed to “vagina or genital opening”). To account for multiple incidences and tactics of sexual assault experiences, a severity scoring method was used that incorporates both severity of victimization experience and frequency of experiences (Davis et al., 2014). Participants were asked how often each sexual experience occurred by each tactic with responses ranging from 0 (never) to 3 (three or more times), and an index score was computed based on severity and frequency, with a 63-point scale maximum. An example score for someone who experienced rape by physical force (severity ranking of 9) one time (frequency of 1) would receive a score of a 9 (9 times 1), while an example score of someone who experienced unwanted contact by verbal coercion (severity ranking of 1) three times (frequency of 3) would receive a score of 3 (1 times 3; see Davis et al., 2014 for more examples).

Alcohol Use

Participants completed the Daily Drinking Questionnaire (Collins et al., 1985) to assess average alcohol drinks per week. Participants estimated the typical number of standard drinks, defined as one 12-ounce beer, one 5-ounce glass of wine, or one 1.5 ounce shot of 80-proof spirits (Zernig et al., 2000), consumed on each day of an average week. Average drinks per week was calculated as the sum of the reported average number of drinks consumed on each day.

Posttraumatic Stress Symptoms

To assess PTSS, the PTSD Checklist-8 (PCL-8; Price et al., 2016) was used. This eight-item survey is a modified version of the PCL-5 which is a validated measure of PTSS using 20 items (Weathers et al., 2013). The PCL-8 has been validated and found to have comparable diagnostic ability to the PCL-5 (Price et al., 2016). Higher scores indicate more PTSS severity. The PCL-8 was administered to all participants in the survey, and the prompt states “Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month.”

Procedure

All study procedures were approved by the institutional review board. Participants completed a 30-min online survey that consisted of demographic items and validated surveys. Participation was incentivized. Participants recruited from psychology classes received class credit, and all other participants received a U.S. $15 gift card for completing the survey. Participants who endorsed any suicidal ideation or risk were provided with the national suicide hotline number. Participants who endorsed any acute risk of suicide on the survey received a phone call from a researcher within 1 day to assess for suicide risk and help connect to the national suicide hotline.

Data Analysis Plan

All analyses were completed in MPlus 8.0 (Muthén & Muthén, 2017), and missing data were handled using robust maximum likelihood. Outcome variables were assessed for normality and if a distribution was nonlinear, then a nonlinear distribution model would be used. Skewness, kurtosis, and number of zeros were examined in the outcome data to determine regression type (e.g., linear or negative binomial). Separate regressions were conducted with the following outcome variables: suicidality (SBQ-R), current urge to self-harm (L-RAMP), and current suicidal intent (L-RAMP). Predictor variables in all analyses will include age, sexual orientation (sexual minority = 1, heterosexual/straight = 0), gender (dummy codes for gender minority and woman compared to man), race and ethnicity (dummy codes for Black, Latine, Asian, Multiracial, and Other race compared to non-Latine White), first-generation college student (yes = 1, no = 0), sexual assault history severity, average drinks per week, and PTSS severity. The regression with suicidality included the entire sample (n = 2,160). The regressions with current urge to self-harm and current suicidal intent included only the sample of participants who were asked these questions (n = 1,429). Effect sizes for the linear regression will be reported using Cohens f with large effect sizes being over 0.40. Effect sizes for the negative binomial regressions are presented using incidence rate ratios (IRRs).

Results

Descriptive Analyses

For descriptive statistics, see Table 1. Over half of participants reported any suicidality (63.5%), 12% reported current urge to harm themselves, and 5% reported current suicidal intent. Bivariate correlations revealed that sexual assault victimization history severity and PTSD symptom severity were both associated with suicidality, current urge to self-harm, and current suicidal intent (see Table 2). Average drinks per week was positively associated with suicidality and current suicidal intent, but not current urge to self-harm (see Table 2).

Table 2.

Bivariate Correlations Among Variables.

Variable Name	1	2	3	4	5	6	7
1. Age	—
2. Sexual assault history severity	.078**	—
3. Average drinks per week	.092**	.185**	—
4. PTSS severity	−.005	.259**	.069**	—
5. Suicidality	−.023	.178**	.068**	.509**	—
6. Current urge to self-harm^a	−.009	.128**	.031	.340**	.451**	—
7. Current intent to suicide^a	−.013	.130**	.053*	.214**	.337**	.463**	—

Note. PTSS = posttraumatic stress symptom.

p < .05. **p < .01.

Suicidality: Linear Regression

The linear regression model was run with the entire sample (n = 2,160). Results of the linear regression indicated that suicidality was higher among those who identify as a sexual minority (B = 0.187; p < .001) compared to heterosexual/straight, or gender minority (B = 0.078; p = .001) compared to those who identify as a man; among those who engage in more alcohol use on average (B = 0.047; p = .045); and among those who had more severe symptoms of PTSD (B = 0.447; p < .001; see Table 3). University was also significantly associated with suicidality (B = 0.073; p < .001). The overall regression had a large effect size (Cohens f = 0.477).

Table 3.

Regression Models.

Suicidality, Linear Regression (n = 2,160)		B	SE	z	p
Age		−0.026	0.018	−1.470	.142
Sexual minority (vs. heterosexual/straight)		0.187	0.022	8.630	<.001
Gender
Gender minority (vs. man)		0.078	0.023	3.310	.001
Woman (vs. man)		−0.011	0.019	−0.567	.571
University		0.073	0.021	3.530	<.001
Race and ethnicity
Black (vs. non-Latine White)		−0.012	0.022	−0.552	.581
Latine (vs. non-Latine White)		−0.018	0.021	−0.849	.396
Asian (vs. non-Latine White)		−0.006	0.021	−0.296	.767
Multiracial (vs. non-Latine White)		0.003	0.018	0.164	.870
Other race (vs. non-Latine White)		−0.030	0.016	−1.871	.061
First-generation college student		0.005	0.020	0.272	.785
Sexual assault history severity		0.040	0.023	1.702	.089
Average drinks per week		0.047	0.024	2.000	.045
PTSS severity		0.447	0.020	22.039	<.001
Current urge to self-harm, negative binomial (n = 1,429)	IRR	B	SE	z	p
Age	0.988	−0.036	0.081	−0.446	.655
Sexual minority (vs. heterosexual/straight)	1.298	0.235	0.086	2.743	.006
Gender
Gender minority (vs. man)	0.939	−0.030	0.096	−0.309	.758
Woman (vs. man)	1.030	0.025	0.098	0.257	.797
University	1.056	0.050	0.091	0.552	.581
Race and ethnicity
Black (vs. non-Latine White)	0.964	−0.027	0.098	−0.273	.785
Latinx (vs. non-Latine White)	0.977	−0.015	0.078	−0.195	.845
Asian (vs. non-Latine White)	1.074	0.053	0.093	0.576	.564
Multiracial (vs. non-Latine White)	0.926	−0.030	0.073	0.073	.679
Other race (vs. non-Latine White)	1.205	0.075	0.068	1.105	.269
First-generation college student	1.118	0.096	0.084	1.141	.254
Sexual assault history severity	1.003	0.124	0.097	1.280	.201
Average drinks per week	1.002	0.023	0.083	0.273	.785
PTSS severity	1.054	0.879	0.049	17.814	<.001
Current suicidal intent, negative binomial (n = 1,429)		B	SE	z	p
Age	0.992	−0.093	0.092	−1.012	.312
Sexual minority (vs. heterosexual/straight)	1.001	0.005	0.106	0.052	.959
Gender
Gender minority (vs. man)	0.993	−0.013	0.143	−0.091	.927
Woman (vs. man)	0.942	−0.208	0.113	−1.844	.065
University	1.002	0.006	0.122	0.052	.958
Race and ethnicity
Black (vs. non-Latine White)	1.042	0.125	0.127	0.982	.326
Latinx (vs. non-Latine White)	0.987	−0.035	0.109	−0.320	.749
Asian (vs. non-Latine White)	1.054	0.158	0.124	1.278	.201
Multiracial (vs. non-Latine White)	0.963	−0.060	0.086	−0.701	.483
Other race (vs. non-Latine White)	1.026	0.042	0.125	0.335	.737
First-generation college student	1.074	0.248	0.109	2.271	.023
Sexual assault history severity	1.002	0.341	0.156	2.187	.029
Average drinks per week	1.003	0.159	0.140	1.139	.255
PTSS severity	1.011	0.751	0.098	7.677	<.001

Note. Significant effects are bolded. IRR = incidence rate ratio; PTSS = posttraumatic stress symptoms.

Current Urge to Self-Harm: Negative Binomial Regression

This negative binomial regression was run with the subsample of participants who were asked this question (n = 1,429). Results of the negative binomial regression indicated that current urge to self-harm was higher among participants who identified as a sexual minority (IRR = 1.298; p = .006) and those who had more severe PTSS (IRR = 1.054; p < .001; see Table 3).

Current Suicidal Intent

This negative binomial regression was run with the subsample of participants who were asked this question (n = 1,429). Results of the negative binomial regression indicated that current suicidal intent was higher among first-generation college students (IRR = 1.074; p = .023), those with more severe sexual assault histories (IRR = 1.002; p = .029), and those with more severe PTSS (IRR = 1.011; p < .001; see Table 3).

Discussion

Given the high rates of death caused by suicide in college-aged populations, this study evaluated associations between suicidality and previously established high risk variables, including sexual assault and alcohol use. This clinically comprehensive study of risk factors related to suicide yielded partial support for the hypotheses. As expected, certain demographic variables and PTSS were associated with suicidality, current urge to self-harm, and current suicidal intent. However, contrary to hypotheses, Black students were not identified as having higher risk for suicide. Of note, alcohol use and history of sexual assault were differentially related to different constructs of suicidality. These partially supported findings suggest that distinct risk factors are related to different aspects of suicidality. To develop more tailored strategies in the prevention of this devastating common cause of death, the association between suicidality and other high risk factors merits further investigation. Results from the current study help increase our base understanding more thoroughly among people with suicidality.

The association of PTSS with all the suicidality constructs is not surprising, given that PTSS is a well-established risk factor for suicidality (Tarrier & Gregg, 2004) and is associated with suicide attempts even after accounting for other mental health disorders (Bryan et al., 2017; Cougle et al., 2009; Sareen et al., 2005). The increased association of individuals diagnosed with PTSD to contemplate or attempt suicide seems to be related to the PTSS rather than the experience of the traumatic event. Pietrzak et al. (2011) assessed suicidality in a trauma-exposed sample and found that it was the individuals with PTSD (vs. those that were trauma exposed and without PTSD) that were more likely to attempt suicide. This differentiation may help explain why PTSD was a more consistent predictor of all suicide-related constructs rather than history of a traumatic event (i.e., sexual assault). Findings from this study corroborate this association: sexual assault was not associated with general suicidality or urge to self-harm. A potential explanation for these (lack of) findings is that PTSD was a stronger predictor of all suicide-related constructs in the current sample. A relatively high proportion of students in the present sample also endorsed PTSS. This is not surprising, given that in a healthy sample of college students, 15.5% of participants endorsed at least one symptom of PTSS (see Table 1). The findings of this study extend the current literature by corroborating previous findings with a diverse sample of college students at two minority-serving institutions. These results highlight the importance of understanding mechanisms responsible for the association between PTSS and suicide-related constructs not only across the lifespan, but also in emerging adulthood, a period where individuals may be more susceptible to harm. One possible mechanism that has been linked between PTSS and suicidality is anxiety sensitivity, defined as an exaggerated fear of anxiety-related sensations (Raines et al., 2017). Given that many college students experience stress, it is possible that those with PTSS may uniquely experience anxiety sensitivity in relation to college stress and therefore have heightened risk of suicide.

Despite research demonstrating the linkage of suicidality with PTSD versus the exposure to a traumatic event, sexual assault history remained a significant predictor of current intent to suicide among college students who reported suicidality. Therefore, while sexual assault was not significantly associated with suicidality more generally, it was associated with current intent to suicide among those who were suicidal. This is particularly concerning given the high rates of sexual assault among college students (Fedina et al., 2018), particularly among women and LGBTQ students more specifically (Cantor et al., 2015). Although more studies evaluating comprehensive models of risk factors are needed to replicate these findings, results suggest that sexual assault history may be a strong predictor of completed suicide, even while accounting for symptoms of PTSD.

With regard to findings related to alcohol use, general drinking was associated with general suicidality, but was not related to current intent or current urges as assessed in the present study. Although consistent with findings that demonstrate increased risk of suicide for individuals with reported alcohol use problems (Barrios et al., 2000; Cherpitel et al., 2004; Yuodelis-Flores & Ries, 2015), the lack of association with more elevated risk management strategies among people reporting suicidality may reflect an emphasis on the “current” assessment in the study. Students are unlikely to be drinking at the time of taking the survey so alcohol use may not have been associated with the “current” measures of urge to self-harm and current suicide intent. Future work should conduct event-level studies to understand the event-level association between drinking and current suicidality. Ecological momentary assessment (EMA) methods may help capture fine-grained variations to more accurately assess the associations among alcohol use, urge to self-harm, and current suicidal intent. Kleiman and Nock (2018) outline methods to assess suicidal thoughts and behaviors using EMA methods, and these suggestions can be used to inform assessment of alcohol use, urge to self-harm, and current suicidal intent to further the findings in the current study.

Consistent with the literature, results from this study demonstrated that students who identified as a sexual minority or a gender minority had significantly more general suicidality and urge to self-harm. It is likely that individuals who identify as a sexual or gender minority are exposed to more daily discrimination experiences and face unique stressors related to systemic discrimination, which in turn may increase suicidal thoughts and behaviors. Furthermore, sexual and gender minorities face unique familial stressors due to stigma, including family rejection, which can increase suicidal thoughts and behaviors. While increased risk of general suicidality for LGBTQ individuals has been demonstrated (e.g., Gnan et al., 2019), current findings contribute to identification of unique risk factors of individuals that are at elevated risk (i.e., among people who are endorsing general suicidality). Sexual and gender minority youth in particular continue to be considered an especially vulnerable population, given that elevated rates of suicidal behavior compared to heterosexual and/or cisgender peers have not seemed to decline over time (Hatchel et al., 2021; Liu R. T. et al., 2019).

Contrary to hypotheses, identification as a Black student was not significantly associated with general suicidality, urge to self-harm, or current suicide intent. Again, although we examined race as associated with suicidal thoughts and behavior, it is generally understood that race may serve as a proxy for experiences of daily and systemic discrimination and unique stressors. One potential explanation for the findings of the current study is that although Black youth suicide is on the rise while White youth suicide has declined, White youth still have higher risk of suicide overall (Lindsey et al., 2019). Another potential explanation for this inconsistency is that both universities are minority-serving universities, and one is situated in a city with the presence of a strong Black community and subsequently potentially high self-acceptance surrounding the students of this study. Given that self-acceptance has been shown to reinforce resilience among Black youth and families (Bauermeister et al., 2007; Brooks et al., 2021; Butler-Barnes et al., 2013), a thriving Black environment is unfortunately a unique setting and may have led to a different pattern of results. Among other unexpected findings with regard to demographic variables, university emerged as a variable that was predictive of general suicidality. Given the diversity just discussed (ethnic and gender minorities, first-generation college student) of the sample across both university locations, this finding was unexpected as a unique predictor of suicidal behavior. There is a dearth of research evaluating university level differences in mental health disorders in general, and this finding should be replicated in other samples with more representation of different university contexts. However, one potential aspect of universities that may influence help seeking behavior related to mental health is a commuter campus environment (Wozny et al., 2008). College campus programs can help reduce the stigma associated with mental health and help facilitate access to mental health services, but the strategies used in commuter campuses may require some tailoring to better engage a non-traditional student population (Mortier et al., 2018).

Strengths and Limitations

This study included a random sample of college students from two diverse universities in the Southeast and Southwestern United States. Although distinct risk factors of suicidality have emerged in previous studies, this comprehensive study includes the assessment of several known risk factors for suicidality in one model of analysis. Another unique contribution of the current study is the assessment of urge to self-harm and current intent to suicide. These two additional constructs were assessed among participants who reported suicidality, a research design that is parallel to a stepped model of care for clinical protocol to assess further for risk management strategies once increased risk of suicidality has been reported. These additional steps of assessment in samples with elevated risk are rarely studied. Thus, findings from this study can help increase the knowledge base about people who have reported elevated suicidality.

Although these findings help address some gaps in the literature, there are several limitations to consider when interpreting the findings. First, the data are cross-sectional in nature; therefore, causation cannot be determined. The current study did not assess for effects of intersecting or overlapping identities. Subsequent research can provide an even more comprehensive understanding of the association between risk factors for suicidality by examining interactions that may reflect groups conferring exponential risk (e.g., individuals who identify as Black and LGBTQ, individuals who identify as LGBTQ and have a history of sexual assault, etc.). Additionally, features of the current sample may limit the generalizability of the results. As previously discussed, one of the samples for this study was drawn from a university in the Southeast United States known as a region with a large thriving Black population; future studies are necessary to extend the findings to other demographic surroundings. However, neither university is listed on the campus pride index for LGBTQ-friendly institutions. Therefore, it is imperative to examine the context of Black and LGBTQ support at the university level. Several researchers have proposed that social ties, such as living in an ethnic enclave, may serve as a protective factor (Curry et al., 2018; Wright & Benson, 2010). Subsequent studies may incorporate information on the composition of participant’s neighborhoods to assess for the impact of neighborhood-level demographics on factors related to suicidality. Finally, although the measure of sexual assault victimization severity is a validated and behaviorally based measure, the way the questions are asked can result in someone reporting two types of sexual assault for one sexual assault experience (i.e., physical force and unwanted contact). Moreover, the measure of posttraumatic stress assessed symptoms in response to a very stressful experience. Therefore, it is possible that students responded to this survey based on a variety of experiences, some that might fit the clinical definition of a Criterion A traumatic event and some that may not. Therefore, although these are the gold standard measures of sexual assault victimization and PTSS, it is important to be aware of their limitations when interpreting findings.

Conclusion

Given the increased prevalence of sexual assault and alcohol use among college populations and the emergence of these variables as risk factors for suicidality, the current study examined the association of demographics, sexual assault, PTSS, and alcohol use with suicidality, current urge to self-harm, and current intent to suicide among a diverse sample of college students. Results demonstrated that symptoms of PTSD were associated with all three constructs of suicidality and those who consumed more drinks per week reported more suicidality. Although sexual assault was not associated with general suicidality as expected, sexual assault history was a predictor of current intent to suicide, suggesting it as a risk factor for completed suicide. These findings have clinical implications for how to tailor risk management strategies for students who have endorsed general suicidality.

Supplemental Material

sj-docx-1-jiv-10.1177_08862605231174698 – Supplemental material for Sexual Assault, Posttraumatic Stress, Alcohol Use, and Suicidality Among Diverse College Students

Supplemental material, sj-docx-1-jiv-10.1177_08862605231174698 for Sexual Assault, Posttraumatic Stress, Alcohol Use, and Suicidality Among Diverse College Students by Amanda K. Gilmore, Cristina M. López, Kelly Nicole Mullican, Kelly Cue Davis, Ruschelle M. Leone, Lindsay M. Orchowski, Debra Kaysen and Angela D. Moreland in Journal of Interpersonal Violence

Supplemental Material

sj-docx-2-jiv-10.1177_08862605231174698 – Supplemental material for Sexual Assault, Posttraumatic Stress, Alcohol Use, and Suicidality Among Diverse College Students

Supplemental material, sj-docx-2-jiv-10.1177_08862605231174698 for Sexual Assault, Posttraumatic Stress, Alcohol Use, and Suicidality Among Diverse College Students by Amanda K. Gilmore, Cristina M. López, Kelly Nicole Mullican, Kelly Cue Davis, Ruschelle M. Leone, Lindsay M. Orchowski, Debra Kaysen and Angela D. Moreland in Journal of Interpersonal Violence

Supplemental Material

sj-docx-3-jiv-10.1177_08862605231174698 – Supplemental material for Sexual Assault, Posttraumatic Stress, Alcohol Use, and Suicidality Among Diverse College Students

Supplemental material, sj-docx-3-jiv-10.1177_08862605231174698 for Sexual Assault, Posttraumatic Stress, Alcohol Use, and Suicidality Among Diverse College Students by Amanda K. Gilmore, Cristina M. López, Kelly Nicole Mullican, Kelly Cue Davis, Ruschelle M. Leone, Lindsay M. Orchowski, Debra Kaysen and Angela D. Moreland in Journal of Interpersonal Violence

Supplemental Material

sj-docx-4-jiv-10.1177_08862605231174698 – Supplemental material for Sexual Assault, Posttraumatic Stress, Alcohol Use, and Suicidality Among Diverse College Students

Supplemental material, sj-docx-4-jiv-10.1177_08862605231174698 for Sexual Assault, Posttraumatic Stress, Alcohol Use, and Suicidality Among Diverse College Students by Amanda K. Gilmore, Cristina M. López, Kelly Nicole Mullican, Kelly Cue Davis, Ruschelle M. Leone, Lindsay M. Orchowski, Debra Kaysen and Angela D. Moreland in Journal of Interpersonal Violence

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health under award numbers R01AA028813 and K01AA028844 and National Institute of Mental Health award number R34MH125706. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

ORCID iDs

Amanda K. Gilmore

Cristina M. López

Kelly Cue Davis

Ruschelle M. Leone

Lindsay M. Orchowski

Angela D. Moreland

Author Biographies

Amanda K. Gilmore, PhD, is an associate professor in the Department of Health Policy & Behavioral Sciences at the School of Public Health at Georgia State University as well as the director of the National Center for Sexual Violence Prevention in the Mark Chaffin Center for Healthy Development. Her research focuses on the prevention of alcohol use, sexual assault, and suicide, as well as secondary prevention of substance use and mental health symptoms after sexual assault.

Cristina López, PhD, is an associate professor at the National Crime Victims Research and Treatment Center in the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina. She received her PhD in clinical psychology at Florida State University with research emphases in the development of depression and anxiety disorders. Dr. López’s current research focuses on identification of barriers to treatment engagement in mental health services, the use of culturally tailored interventions as a means of engaging high-risk groups in prevention and behavioral health services, and increasing access of trauma-related services to vulnerable populations.

Kelly Nicole Mullican, PhD, is the lab manager of the Alcohol and Sexual Assault Prevention Lab National Center for Sexual Violence Prevention in the Mark Chaffin Center for Healthy Development at Georgia State University. Nicole has a strong background in applied child welfare research and has collaborated with the Oregon Department of Human Services on efforts to improve foster parent support and retention.

Kelly Cue Davis, PhD, is an Associate Professor at Arizona State University as well as a licensed clinical psychologist. Dr Davis researches the effects of alcohol and drug consumption on sexual violence victimization and perpetration, sexual risk, and sexual health. She has served as Principal Investigator or Co-Investigator on several research projects related to sexual violence and sexual risk, with grant funding from the National Institutes of Health and Department of Defense totaling over $30 million, including the prestigious NIH MERIT award.

Ruschelle M. Leone, PhD, is an assistant professor in the Department of Health Policy and Behavioral Sciences and the Mark Chaffin Center for Healthy Development within the School of Public Health at Georgia State University. Her research focuses on informing and developing intervention programming to reduce alcohol misuse and interpersonal violence.

Lindsay M. Orchowski, PhD, is an associate professor (Research) in the Department of Psychiatry and Human Behavior at the Warren Alpert Medical School of Brown University and a staff psychologist at Rhode Island Hospital. Her research focuses on the development and evaluation of violence prevention programs.

Debra Kaysen, PhD, is a clinical psychologist, and a professor in the Department of Psychiatry & Behavioral Sciences at Stanford University. Her area of specialty both in research and clinical work is in the care of those who have experienced traumatic events including treatment of PTSD and comorbid disorders. Her body of research is notable for the inclusion of underserved populations such as research with Native Americans, sexual minorities, and individuals in low- and middle-income countries.

Angela D. Moreland, PhD, is an associate professor at the National Crime Victims Research and Treatment Center in the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina. Dr. Moreland’s research interests focus on primary and secondary prevention of child abuse and risk factors for maltreatment among high risk parents of young children (i.e., substance use, teen pregnancy); as well as dissemination and implementation of evidence-based practice for victims of interpersonal violence and their families. Dr. Moreland also examines the link between victimization and high-risk behaviors, such as substance use and delinquency, among children and adolescents.

References

Barrios

L. C.

Everett

S. A.

Simon

T. R.

Brener

N. D.

(2000). Suicide ideation among US college students: Associations with other injury risk behaviors. Journal of American College Health, 48(5), 229–233.

Bauermeister

J. A.

Zimmerman

M. A.

Barnett

T. E.

Caldwell

C. H.

(2007). Working in high school and adaptation in the transition to young adulthood among African American youth. Journal of Youth and Adolescence, 36, 877–890.

Boyraz

Horne

S. G.

Armstrong

A. P.

Owens

A. C.

(2015). Posttraumatic stress predicting depression and social support among college students: Moderating effects of race and gender. Psychological Trauma Theory Research Practice and Policy, 7(3), 259–268.

Brooks

J. R.

Madubata

I. J.

Jewell

R. D.

Ortiz

D. A.

Walker

R. L.

(2021). Depression and suicide ideation: The role of self-acceptance for Black young adults. Journal of Black Psychology. Advance online publication. https://doi.org/10.1177/00957984211037440

Bryan

C. J.

Grove

J. L.

Kimbrel

N. A.

(2017). Theory-driven models of self-directed violence among individuals with PTSD. Current Opinion in Psychology, 14, 12–17.

Butler-Barnes

S. T.

Chavous

T. M.

Hurd

Varner

(2013). African American adolescents’ academic persistence: A strengths-based approach. Journal of Youth and Adolescence, 42(9), 1443–1458. https://doi.org/10.1007/s10964-013-9962-0

Cantor

Fisher

Chibnall

Bruce

Townsend

Thomas

Hyunshik

(2015). Report on the AAU campus climate survey on sexual assault and sexual misconduct. https://www.aau.edu/key-issues/aau-climate-survey-sexual-assault-and-sexual-misconduct-2015

Centers for Disease Control and Prevention. (2018). Deaths, percent of total deaths, and death rates for the 15 leading causes of death: United States and each state, 2017 (Mortality 2017). National Vital Statistics System.

Cherpitel

C. J.

Borges

G. L.

Wilcox

H. C.

(2004). Acute alcohol use and suicidal behavior: A review of the literature. Alcoholism Clinical and Experimental Research, 28(5 Suppl), 18S–28S.

10.

Collins

R. L.

Parks

G. A.

Marlatt

G. A.

(1985). Social determinants of alcohol consumption: The effects of social interaction and model status on the self-administration of alcohol. Journal of Consulting and Clinical Psychology, 53, 189–200.

11.

Congressional Black Caucus Emergency Taskforce on Black Youth Suicide and Mental Health. (2019). Ring the alarm: The crisis of black youth suicide in America [White paper]. https://watsoncoleman.house.gov/imo/media/doc/full_taskforce_report.pdf

12.

Cougle

J. R.

Keough

M. E.

Riccardi

C. J.

Sachs-Ericsson

(2009). Anxiety disorders and suicidality in the National Comorbidity Survey-replication. Journal of Psychiatric Research, 43, 825–829.

13.

Curry

T. R.

Morales

M. C.

Zavala

Hernandez

J. L.

(2018). Why is family violence lower among Mexican immigrants? The protective features of Mexican culture. Journal of Family Violence, 33, 171–184.

14.

Curtin

S. C.

(2020). Suicide rates among adolescents and young adults aged 10–24; United States, 2000–2018. National Vital Statistics Reports, 69(11), 1–10.

15.

Davis

K. C.

Gilmore

A. K.

Stappenbeck

C. A.

Balsan

M. J.

George

W. H.

Norris

(2014). How to score the Sexual Experiences Survey? A comparison of nine methods. Psychology of Violence, 4, 445–461.

16.

Delker

Brown

Hasin

D. S.

(2016). Alcohol consumption in demographic subpopulations: An epidemiologic overview. Alcohol Research: Current Reviews, 38(1), 7–15.

17.

Dermody

S. S.

Marshal

M. P.

Cheong

Burton

Hughes

Aranda

Friedman

M. S.

(2014). Longitudinal disparities of hazardous drinking between sexual minority and heterosexual individuals from adolescence to young adulthood. Journal of Youth and Adolescence, 43(1), 30–39.

18.

Dworkin

E. R.

Menon

S. V.

Bystrynski

Allen

N. E.

(2017). Sexual assault victimization and psychopathology: A review and meta-analysis. Clinical Psychology Review, 56, 65–81.

19.

Fedina

Holmes

J. L.

Backes

B. L.

(2018). Campus sexual assault: A systematic review of prevalence research from 2000 to 2015. Trauma Violence & Abuse, 19, 76–93.

20.

Fish

J. N.

Hughes

T. L.

Russell

S. T.

(2018). Sexual identity differences in high-intensity binge drinking: Findings from a US national sample. Addiction, 113(4), 749–758.

21.

Gnan

G. H.

Rahman

Ussher

Baker

West

Rimes

K. A.

(2019). General and LGBTQ-specific factors associated with mental health and suicide risk among LGBTQ students. Journal of Youth Studies, 22(10), 1393–1408.

22.

Gradus

J. L.

(2018). Posttraumatic stress disorder and death from suicide. Current Psychiatry Reports, 20(11), 98.

23.

Grant

B. F.

Goldstein

R. B.

Saha

T. D.

Chou

S. P.

Jung

Zhang

Pickering

R. P.

Ruan

W. J.

Smith

S. M.

Huang

Hasin

D. S.

(2015). Epidemiology of DSM-5 alcohol use disorder: Results from the National Epidemiologic Survey on alcohol and related conditions III. JAMA psychiatry, 72(8), 757–766. https://doi.org/10.1001/jamapsychiatry.2015.0584

24.

Hafeez

Zeshan

Tahir

M. A.

Jahan

Naveed

(2017). Health care disparities among lesbian, gay, bisexual, and transgender youth: A literature review. Cureus, 9(4), e1184.

25.

Hatchel

Polanin

J. R.

Espelage

D. L.

(2021). Suicidal thoughts and behaviors among LGBTQ youth: Meta-analyses and a systematic review. Archives of Suicide Research, 25(1), 1–37.

26.

Kerridge

B. T.

Pickering

R. P.

Saha

T. D.

Ruan

W. J.

Chou

S. P.

Zhang

Jung

Hasin

D. S.

(2017). Prevalence, sociodemographic correlates and DSM-5 substance use disorders and other psychiatric disorders among sexual minorities in the United States. Drug and Alcohol Dependence, 170, 82–92.

27.

Kleiman

E. M.

Nock

M. K.

(2018). Real-time assessment of suicidal thoughts and behaviors. Current Opinion in Psychology, 22, 33–37.

28.

Koss

M. P.

Abbey

Campbell

Cook

Norris

Testa

Ullman

West

White

(2007). Revising the SES: A collaborative process to improve assessment of sexual aggression and victimization. Psychology of Women Quarterly, 31, 357–370. https://doi.org/10.1111/j.1471-6402.2007.00385.x

29.

Lindsey

M. A.

Sheftall

A. H.

Xiao

Joe

(2019). Trends of suicidal behaviors among high school students in the United States: 1991-2017. Pediatrics, 144, e20191187. https://doi.org/10.1542/peds.2019-1187

30.

Linehan

M. M.

Comtois

K. A.

Ward-Ciesielski

E. F.

(2012). Assessing and managing risk with suicidal individuals. Cognitive and Behavioral Practice, 19(2), 218–232.

31.

Liu

C. H.

Stevens

Wong

S. H. M.

Yasui

Chen

J. A.

(2019). The prevalence and predictors of mental health diagnoses and suicide among US college students: Implications for addressing disparities in service use. Depression and Anxiety, 36(1), 8–17.

32.

Liu

R. T.

Sheehan

A. E.

Walsh

R. F. L.

Sanzari

C. M.

Cheek

S. M.

Hernandez

E. M.

(2019). Prevalence and correlates of non-suicidal self-injury among lesbian, gay, bisexual, and transgender individuals: A systematic review and meta-analysis. Clinical Psychology Review, 74, 101783.

33.

Dorstyn

D. S.

Jarmon

(2020). Identifying suicide risk among college students: A systematic review. Death Studies, 44(7), 450–458.

34.

Mackenzie

Wiegel

J. R.

Mundt

Brown

Saewyc

Heiligenstein

Harahan

Fleming

(2011). Depression and suicide ideation among students accessing campus health care. American Journal of Orthopsychiatry, 81(1), 101–107.

35.

Miranda-Mendizábal

Castellví

Parés-Badell

Almenara

Alonso

Blasco

M. J.

Cebrià

Gabilondo

Gili

Lagares

Piqueras

J. A.

Roca

Rodríguez-Marín

Rodríguez-Jiménez

Soto-Sanz

Vilagut

Alonso

(2017). Sexual orientation and suicidal behaviour in adolescents and young adults: Systematic review and meta-analysis. The British Journal of Psychiatry, 211(2), 77–87.

36.

Mortier

Auerbach

R. P.

Alonso

Bantjes

Benjet

Cuijpers

Ebert

D. D.

Green

J. G.

Hasking

Nock

M. K.

O'Neill

Pinder-Amaker

Sampson

N. A.

Vilagut

Zaslavsky

A. M.

Bruffaerts

Kessler

R. C.

& Who Wmh-ics Collaborators. (2018). Suicidal thoughts and behaviors among first-year college students: Results from the WMH-ICS Project. Journal of the American Academy of Child and Adolescent Psychiatry, 57(4), 263–273.

37.

Muthén

L. K.

Muthén

B. O.

(2017). Mplus: Statistical Analysis with Latent Variables: User’s Guide (Version 8). Los Angeles, CA: Authors.

38.

National Institute on Alcohol Abuse and Alcoholism. (2019). Alcohol and “deaths of despair” NIAAA Spectrum, Vol 11, Issue 2. U.S. Department of Health and Human Services, National Institutes of Health. https://www.spectrum.niaaa.nih.gov/Content/archives/Fall_2019.pdf

39.

Osman

Bagge

C. L.

Gutierrez

P. M.

Konick

L. C.

Kopper

B. A.

Barrios

F. X.

(2001). The Suicidal Behaviors Questionnaire-Revised (SBQ-R): Validation with clinical and nonclinical samples. Assessment, 8, 443–454.

40.

Pietrzak

R. H.

Goldstein

R. B.

Southwick

S. M.

Grant

B. F.

(2011). Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from Wave 2 of the National Epidemiologic Survey on alcohol and related conditions. Journal of Anxiety Disorders, 25(3), 456–465.

41.

Price

Szafranski

D. D.

van Stolk-Cooke

Gros

D. F.

(2016). Investigation of abbreviated 4 and 8 item versions of the PTSD Checklist 5. Psychiatry Research, 239, 124–130.

42.

Raines

A. M.

Walton

J. L.

McManus

E. S.

Cuccurullo

L. A. J.

Chambliss

Uddo

Franklin

C. L.

(2017). Associations between lower order anxiety sensitivity dimensions and DSM-5 posttraumatic stress disorder symptoms. Cognitive Behaviour Therapy, 46, 162–173.

43.

Read

J. P.

Ouimette

White

Colder

Farrow

(2011). Rates of DSM-IV-TR trauma exposure and posttraumatic stress disorder among newly matriculated college students. Psychological Trauma Theory Research Practice and Policy, 3(2), 148–156.

44.

Sareen

Houlahan

Cox

B. J.

Asmundson

G. J.

(2005). Anxiety disorders associated with suicidal ideation and suicide attempts in the National Comorbidity Survey. The Journal of Nervous and Mental Disease, 193, 450–454.

45.

Stebleton

M. J.

Kaler

L. S.

Potts

(2022). Am I even going to be well-liked in person?”: First-year students’ social media use, sense of belonging, and mental health. Journal of College and Character, 23(3), 210–226.

46.

Stephenson

J. H.

Belesis

M. P.

Balliet

W. E.

(2005). Variability in college student suicide: Age, gender, and race. Journal of College Student Psychotherapy, 19(4), 5–33.

47.

Talley

A. E.

Gilbert

P. A.

Mitchell

Goldbach

Marshall

B. D.

Kaysen

(2016). Addressing gaps on risk and resilience factors for alcohol use outcomes in sexual and gender minority populations. Drug and Alcohol Review, 35(4), 484–493.

48.

Tarrier

Gregg

(2004). Suicide risk in civilian PTSD patients—predictors of suicidal ideation, planning and attempts. Social Psychiatry and Psychiatric Epidemiology, 39, 655–661.

49.

Uchida

(2017). Characteristics and risk factors for suicide and deaths among college students: A 23-year serial prevalence study of data from 8.2 million Japanese college students. Journal of Clinical Psychiatry, 78(04), e404–e412.

50.

Ullman

S. E.

Brecklin

L. R.

(2002). Sexual assault history and suicidal behavior in a national sample of women. Suicide and Life-Threatening Behavior, 32, 117–130.

51.

Weathers

F. W.

Blake

D. D.

Schnurr

P. P.

Kaloupek

D. G.

Marx

B. P.

Keane

T. M.

(2013). The life events checklist for DSM-5 (LEC-5). Instrument available from the National Center for PTSD at www.ptsd.va.gov.

52.

World Health Organization. (2019). Suicide in the world: Global health estimates. (No. WHO/MSD/MER/19.3).

53.

Wozny

D. A.

Porter

J. Y.

Watson

J. C.

(2008). Commuter campus suicide prevention program challenges: Engaging nontraditional students and college faculty/staff. In Walz

G. R.

Bleuer

J. C.

Yep

R. K.

(Eds.), Compelling counseling interventions: Celebrating vistas’ fifth anniversary (pp. 187–197). Counseling Outfitters.

54.

Wright

E. M.

Benson

M. L.

(2010). Immigration and intimate partner violence: Exploring the immigrant paradox. Social Problems, 57, 480–503.

55.

Yuodelis-Flores

Ries

R. K.

(2015). Addiction and suicide: A review. American Journal on Addictions, 24(2), 98–104.

56.

Zernig

Saria

Kurz

O’Malley

S. S.

(2000). Definitions of a `standard drink’. In Zernig

Saria

Kurz

O’Malley

S. S.

(Eds.), Handbook of Alcoholism (pp. 429). CRC Press.

57.

Zhang

Lester

Zhao

Zhou

(2013). Suicidal ideation and its correlates: Testing the interpersonal theory of suicide in Chinese students. Archives of Suicide Research, 17(3), 236–241.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.05 MB

0.02 MB