Suicide risk and help-seeking among international students

Suicide is a leading cause of death for young people aged 15–29 (World Health Organization, 2021b), and rates are particularly elevated in students enrolled in post-secondary education such as university or college (Mortier et al., 2018). International college students represent a large proportion of post-secondary students in many countries (In 2021: Australia = 22%, Canada = 17%, UK = 20%, U.S. = 5% OECD, 2023), and suicidal thoughts and behaviors are common among this group (Veresova et al., 2024).

Evidence predominantly from the U.S. indicates varying rates of suicidality among international students across different contexts. In general student populations, international students show similar past year suicidal ideation (5.6–9.8% vs. 5.2–13.3% for domestic students) and self-harm (4.3–17.2% vs. 3.2–22.9% for domestic students 3.2–22.9%; Goodwill and Zhou, 2020; Yeung et al., 2021; Xiong and Pillay, 2022; Zhou et al., 2022). However, concerning trends emerge when examining more severe outcomes. In general student populations, international students report higher rates of past year suicide attempts (1.21–2.2%) in comparison to domestic students [0.1–1.6% (Goodwill and Zhou, 2020; Yeung et al., 2021; Xiong and Pillay, 2022)] and this disparity is even more pronounced in clinical settings. For instance, among students seeking psychiatric services, international students show a higher lifetime history of multiple attempts for those seeking psychiatric services (international = 14.3%, domestic = 6.5%; Hong et al., 2022). This is particularly troubling, as suicide attempts are a significant risk factor for future suicide attempts and deaths (Ribeiro et al., 2016). Despite these elevated rates of suicide attempts, there is a scarcity of research that uncovers the risk and protective factors associated with suicide-related thoughts and behaviors among international college students (Veresova et al., 2024).

Risk and protective factors play crucial roles in understanding and predicting suicide-related outcomes (Fonseca-Pedrero et al., 2022). Risk factors are characteristics or conditions that increase the likelihood of suicidal thoughts or behaviors, while protective factors are elements that reduce this risk and promote resilience (Fonseca-Pedrero et al., 2022). These factors interact dynamically, with protective factors potentially mitigating the impact of risk factors (Allen et al., 2022).

Research on the risk and protective factors for suicidality among international students can be grouped into three main areas, many of which are associated with acculturation challenges arising from adapting to a new culture, education system, and country (Orygen, 2020; Veresova et al., 2024). The first set of risk factors include experiences of social isolation, with loneliness, unmet personal needs, and low social support and campus belongingness all related to increased suicidal ideation and self-harming behaviors (Servaty-Seib et al., 2016; Taliaferro et al., 2020; Nguyen et al., 2021; Low et al., 2023). The second category includes intrapersonal factors (i.e., individual level factors) such as depression, anxiety, maladaptive perfectionism, hopelessness, and low problem-focused coping, which have been shown to increase risk for suicidal ideation and self-harm (Yang and Clum, 1994; Wang et al., 2013; Jun et al., 2022; Low et al., 2023). Lastly, contextual factors, including perceived discrimination, academic and life stress, and unmet family expectations of academic performance, are each related to suicidal ideation, with perceived public stigma, particularly amongst Asian international students, predicting suicide attempts (Goodwill and Zhou, 2020; Taliaferro et al., 2020; Pérez-Rojas et al., 2021; Low et al., 2023). Many of these factors can also be protective when reversed. For instance, high levels of problem-focused coping and social and university connectedness serve as buffers against suicidality when experiencing stressful life events (Low et al., 2023). Other protective factors include greater cultural sanctions against suicide and family cohesion in the form of high warmth and low conflict (Taliaferro et al., 2020). While research has identified these factors, numerous other potential risk and protective factors for international students have yet to be tested in relation to suicidal thoughts and behaviors despite being identified as predictors of poor mental health and implicated in international student suicide deaths.

Key predictors of poor mental health among international students include language difficulties, acculturation issues, cross-cultural loss, and financial stress (Zhang and Goodson, 2011; Minutillo et al., 2020). Although published research on international student suicide deaths is scarce, several coronial investigations into such cases in Australia have revealed that a variety of stressors, including those outlined above, often are linked to death by suicide (Jamieson, 2019, 2021; McGregor, 2023). These investigations also highlight that students often did not seek or engage with university or mental health support services before the suicides occurred.

Research into the barriers facing international students in seeking help and utilizing services indicates that cultural stigma, limited mental health literacy, and structural obstacles like unavailable, unaffordable, or culturally misaligned services can significantly hinder help-seeking and service utilization (Lu et al., 2014; Clough et al., 2019; Jamieson, 2021). Cultural stigma regarding mental health concerns relates to both perceptions of weakness or “craziness” associated with mental health issues along with potential consequences for individual or family reputations (Ma et al., 2021). Similarly, international students often report concerns regarding potential consequences such as losing their visa or academic issues if they report mental health issues (Orygen, 2020). Poor symptom recognition can also contribute to the problem, with many international students unaware that their experiences and symptoms are representative of mental health problems (Lu et al., 2014). Lastly, even when international students overcome these issues, they are more likely to drop out of treatment than domestic students, and it has been suggested that this is because available services are often not aligned with cultural expectations (Bartholomew et al., 2022).