Maria Veresova
Michelle Lamblin1,2
Jo Robinson
Samuel McKay- 1Orygen, Parkville, VIC, Australia
- 2Center for Youth Mental Health, The University of Melbourne, Parkville, VIC, Australia
International students are a crucial group for suicide prevention efforts. However, no comprehensive review of the prevalence, risk or protective factors for international student suicide has been conducted, complicating prevention efforts. The current systematic review addresses this issue by identifying the prevalence, risk, and protective factors for suicidal thoughts and behavior in international students enrolled in tertiary institutions. We searched CINAHL, EMBASE, ERIC, Medline, and PsycInfo from inception to November 2023, and 24 papers met the study inclusion criteria. Nineteen studies reported on the prevalence or intensity of suicidal ideation, six reported on the prevalence of suicide attempts, and seven on the prevalence of self-harm. No studies provided data on completed suicides. Studies indicated that international students experienced similar or lower levels of suicidal ideation and self-harm, but more frequent suicide attempts than domestic students. A narrative synthesis of risk and protective factors yielded mixed results, although social isolation, comorbid mental health conditions, and experiences of racism or discrimination were commonly linked to suicidal thoughts and behaviors. The mixed evidence quality, numerous measurement issues, and low number of studies in the literature point to a need for further research on suicide among international students.
Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022307252.
Introduction
Suicide has been one of the leading causes of death worldwide in the recent years (1–3). Suicidal thoughts and behaviors are particularly prevalent among tertiary education students (4). A significant portion of students in higher education are international students who transition from their primary country of residence to pursue education abroad (5, 6). International students face a unique combination of challenges such as language barriers, cultural adjustment, financial stress, and academic pressure (7). These factors can negatively impact mental health (8, 9) and potentially increase the risk of suicidal thoughts and behaviors. Complicating matters, international students are less likely to seek help for mental health-related struggles compared to domestic students (10). Furthermore, recent investigations into international student suicides highlight that these students’ engagement with mental health services prior to their death is minimal (11).
Despite evidence suggesting that international students may experience multiple risk factors for suicide, there has been little focus on this population when it comes to suicide prevention research (12). A recent scoping review found that there is a lack of high-quality research on this topic, and that no suicide-specific interventions for international students currently exist (13). Encouragingly, broader suicide prevention activities delivered in tertiary education institutions have been shown to improve students’ knowledge and attitudes towards suicide and rates of engagement with mental health services (14). However, such programs may not be appropriate or adapted to international student needs. People from culturally and linguistically diverse backgrounds have distinct perspectives on mental health and suicide, and effective suicide prevention for these groups necessitates tailored strategies (13, 15). Foundational to this is epidemiological research that identifies potential points for intervention. Currently, there is a gap in knowledge regarding the prevalence rates of, and risk factors for, suicidal thoughts and behaviors in international students. This limits our capacity to develop effective, evidence-based suicide prevention interventions for this population.
The present review aims to address these gaps by synthesizing the available literature on suicide and suicide related behaviors in international students by answering the following questions: a) What is the prevalence of suicidal ideation, suicide attempts and self-harm in international students, and b) What are the risk and protective factors that influence suicides, suicidal ideation, attempts, and self-harm in international students?
Materials and methods
The protocol for this review was registered on PROSPERO (CRD42022307252). The summary of prevalence rates of suicidal thoughts and behaviors was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (16). Because studies that examined risk and protective factors for suicidal thoughts and behaviors varied considerably in their methodologies and variables of interest, narrative synthesis was deemed most appropriate to summarize the findings. The narrative synthesis approach was guided by Rodgers et al. (17).
Eligibility criteria
The inclusion criteria comprised peer-reviewed empirical studies that a) identified rates of suicidal ideation, attempts, or self-harm, or b) examined risk or protective factors for suicide, suicidal ideation, attempts, or self-harm in international students.
International students were defined as tertiary education students of any age enrolled in an educational program in a different country to where they typically reside or hold citizenship. Studies were included if international student participants made up the entire sample or were identified as a subset of a broader sample with their data reported separately. Studies from any publication year and geographical region were included. Case studies and qualitative studies were excluded as the current review focused specifically on quantitative evidence. Sources that were not in English were excluded due to resource limitations.
Search strategy and data sources
A comprehensive search strategy was developed with support from a librarian to identify published articles relevant to the research questions. Two platforms (EBSCOhost & OVID) covering five databases (CINAHL, EMBASE, ERIC, Medline, & PsycINFO) were searched to cover a variety of disciplines (e.g., health, psychology, and education) relevant to the research topic. Search terms were adapted for each platform and database. Searches included studies from the database inception to 8 November, 2023. Reference lists from identified studies were checked for any additional relevant studies that may have been missed during the electronic search. The full search strategy is reported in Appendix A.
Reference management and screening
All search results were imported into Endnote, duplicates were checked and removed, and the full reference list was generated and uploaded to the systematic review screening tool Covidence (18). Additional duplicate checks were undertaken in Covidence. SM performed the database search, combined the records, and ran the duplicate removal processes. Titles and abstracts were independently screened for relevance to the research question and inclusion criteria by MV and SM. Full texts of included articles were then screened for more detail by the same two reviewers. All full-text studies that were excluded had their reasons for exclusion recorded. Discrepancies in screening decisions between the two reviewers were discussed until consensus was reached.
Data extraction and analysis
A tailored data extraction template was created (Appendix B) to extract incidence of suicide, prevalence rates of suicide attempts and self-harm, and prevalence rates and intensity levels of suicidal ideation. In this review, a risk or protective factor was conceptualized as any variable that was defined, measured, and tested for a statistically significant relationship with suicide, suicidal ideation, attempts, or self-harm, through any type of analysis (e.g., correlation or regression). SM and MV independently performed data extraction for each included article, and subsequently verified the extraction results for accuracy.
Quality assessment
Quality assessment was performed using the Checklist for Assessing the Quality of Quantitative Studies (CAQQS) (19) as this tool provides a comprehensive evaluation of the methodological quality of research. All studies were included in the final review regardless of how they scored on the CAQQS.
Results
Selection of sources of evidence
The process of searching, retrieving, and screening studies is described in Figure 1. The inter-rater reliability between the two reviewers was κ = 0.66 [substantial (20)] for the abstract screening and κ = 0.85 (almost perfect agreement) for the full-text screening. Twenty-four studies were included in the final review, and their key characteristics and quality assessment scores are reported in Table 1.
Figure 1 The PRISMA flowchart describing the process of systematic search and study selection.
Table 1 Summary of included studies and relevant key findings.
Characteristics of included studies
Of 24 studies, 21 were published between 2013 and 2023, and three prior to that (34, 41, 42). Fifteen studies were conducted in the USA; the remainder came from Asia (3), Australia (3), Europe (2), and Canada (1). There were 21 cross-sectional studies, one case series (24), one longitudinal (26), and one case-control study (40). The included studies scored between 63.6% and 95.5% on the CAQQS tool. Most studies were not guided by a suicide-specific theoretical framework, while four (32, 33, 36, 39) referenced the Interpersonal Theory of Suicide (49).
Ten studies consisted solely of international students, and fourteen had an international student sub-sample and reported their demographic information separately. Because Yang and Clum’s two studies (41, 42) used the same sample, from hereon it will be counted only once when reporting demographic data and suicide-related outcomes. The sizes of international student samples and sub-samples ranged from 46 to 22,385 with a median of 334.0. Where international students comprised a sub-sample, their proportion of the overall sample ranged from 4.6% to 75.0% ( = 30.1%).
On average, international student samples had a slightly higher proportion of females (range = 27.7-68.0%, = 56.1%) than males (32.0-72.3%, = 43.9%). Twelve studies reported mean ages of international students (range = 20.2-28.5 years, = 23.7). Six studies reported only age ranges (18-30+), and five did not report age. All samples consisted of college or university students at the undergraduate or postgraduate level. Most international students were from Asia, with China and India being the most common countries of origin.
Prevalence and intensity of suicidal thoughts and behaviors
Suicidal ideation
Nineteen studies reported on suicidal ideation in international students using a diverse range of measures and timeframes. In terms of prevalence rates, one study found that 46.0% of students presenting at a psychiatric emergency clinic reported suicidal ideation in the past week, measured by the Columbia Suicide Severity Rating Scale (C-SSRS) (24). The proportions of students endorsing suicidal ideation in the past two weeks were 28.6% (22) and 23.4% (32) when measured by item 9 from the Patient Health Questionnaire-9, and 21.8% when measured by the Modified Scale for Suicide Ideation (41, 42). According to one study, 6-month prevalence of suicidal ideation was 11.2%, measured by the C-SSRS (26). Five studies reported on prevalence in the past year, yielding a range of 5.4-18.2% (23, 37, 40, 43, 44). This was measured by various purpose-built questions or items borrowed from existing measures. Prevalence of suicidal ideation since commencing study abroad was 11.3% in females and 6.7% in males, as measured by a purpose-built question (34). Lifetime prevalence of suicidal ideation was 26.0% (26).
Five studies measured the intensity of suicidal ideation in the past week. The mean scores were 13.00 and 12.99 on the Suicidal Ideation Scale (full range 10-50) (33, 39), 3.11 on the Beck Scale for Suicide Ideation (BSSI; full range 0-42) (27), 0.38 on the first five items of the BSSI (full range 0-10) (29), and 1.14 on a purpose-built question (full range 1-5) (21). The mean score for Jun and colleagues’ (25) sample on the BSSI was 11.30, but no timeframe was reported.
Five studies compared prevalence rates of suicidal ideation between international and domestic students. International students had significantly lower rates of suicidal ideation than domestic students in three of those studies (23, 43, 44) and similar rates to domestic students in the two remaining studies (24, 26). There was an additional study where international students reported higher rates than domestic students, but it was not stated whether this difference was statistically significant (40).
Three studies compared the intensity of suicidal ideation between international and domestic students. International students had similar intensity levels to domestic students in two studies (21, 36) and significantly higher levels than domestic students in one study (27).
Suicide attempts
Six studies provided data on prevalence rates of suicide attempts in international students. In one study, the rate of suicide attempts in the past week was 12.7% (24). In another study, 6-month prevalence was 3.5% (26). Four studies reported rates of attempts in the past year, ranging from 1.2% to 2.2% (23, 37, 40, 43). As for lifetime suicide attempts, the prevalence was 7.5% (26), while in another study with students presenting to a psychiatric emergency clinic, lifetime prevalence of multiple attempts (2+) was 14.3% (24). Four studies assessed suicide attempts using purpose-built questions that were not part of existing measures, and the remaining two used the C-SSRS (24, 26).
Five studies compared international and domestic students on the prevalence of suicide attempts, yielding mixed results. Rates over the past year were significantly higher in international than domestic students in two studies (23, 43). There was a third study where international students also reported higher suicide attempt rates than domestic students, but this difference was not tested for significance (40). In one study, international and domestic students did not differ on lifetime prevalence of attempts at entry to college, but at 6-month follow-up international students were significantly more likely to have made an attempt than domestic students (26). Another study reported that while international and domestic students accessing psychiatric services did not differ on past-week attempt rates, international students had a higher lifetime prevalence of multiple attempts than domestic students (24).
Suicides
No studies reported rates of completed suicide.
Self-harm
Six studies measured and reported self-harm rates in international students. Among students presenting at a psychiatric emergency clinic 12.7% reported engaging in self-harm in the past week (24), whereas 6-month prevalence of self-harm was 5.6% in a general university sample (26). Three studies reported on past-year rates of self-harm, which ranged from 4.8% to 17.2% (40, 43, 44). Prevalence of self-harm since commencing study abroad was 4.5% in females and 2.0% in males (34). Lifetime prevalence was 13.0% in one study (26), while 25.4% of international students presenting to psychiatric services reported a lifetime history of multiple self-harm instances (2+) (24). Five of the six studies used purpose-built questions as opposed to a standardized measure; the study by King et al. (26) used the C-SSRS.
Studies that compared the rates of self-harm in international and domestic students reported mixed results. Three studies found no difference in self-harm rates (24, 26, 43), while in one study international students had lower rates of self-harm than domestic students (44).
Narrative synthesis of risk and protective factors for suicidal thoughts and behaviors
Suicidal ideation
Several factors related to social isolation emerged as risk factors for suicidal ideation. Three studies found an association between low social support and suicidal ideation (32, 41, 42). High social support was a protective factor, but this association was weaker for international than domestic students (32). Another factor related to suicidal ideation was low campus belongingness in two studies (29, 36), while unmet interpersonal needs (37) and loneliness (29) were factors identified by single studies. Conversely, high family belongingness emerged as a potential risk factor, with international students reporting higher suicidal ideation at higher levels of family connectedness (36).
There were numerous intrapersonal factors relating to a person’s psychological functioning that emerged as risk factors. Three studies found a relationship between depression and suicidal ideation (25, 39, 41), while single studies identified the following as risk factors: generalized anxiety, social anxiety, eating concerns, hostility, maladaptive perfectionism (25); personal discrepancy between desired and actual educational performance (39); low problem-focused coping skills and hopelessness (41).
Several contextual factors related to an individual’s external setting emerged as risk factors. Suicidal ideation was associated with perceived discrimination in three studies (33, 37, 39), academic stress in two studies (25, 33), life stress in two studies (29, 41), and family discrepancy between desired and actual educational performance in two studies (25, 39). Single studies identified a relationship of suicidal ideation with the following factors: cross-cultural loss (33); perceived public stigma (23); residing with family, perceived susceptibility to COVID-19, and perceived insufficiency with resources needed to prevent COVID-19 (21).
There was mixed evidence for several potential risk factors. There were no gender differences on suicidal ideation in two studies (21, 36), but in Zhou and colleagues’ study (44) rates of suicidal ideation were significantly higher in females (9.9%) than males (7.0%). Similarly in King et al. (26), more females than males reported suicidal ideation at both entry to college (35.3% vs. 20.5%) and at 6-month follow-up (15.3% vs. 7.5%), but this difference was not tested for statistical significance. Of the three studies that assessed perceived burdensomeness, two reported a significant association (33, 39) and one did not (36). Additionally, several factors correlated with suicidal ideation but did not predict it when using predictive models (e.g., regression analyses or structural equation modelling), namely thwarted belongingness (33, 39), cultural stress, family conflict, feelings of entrapment, and perfectionism (37).
Suicide attempts
Two studies assessed risk or protective factors related to suicide attempts. Higher perceived public stigma was associated with greater incidence of attempts, and this association was stronger in Asian international than white students (23). Among international students, males had a higher prevalence of attempts than females, but whether this difference was significant was not reported (26). Being a Chinese versus non-Chinese international student was not associated with differing prevalence of attempts (26).
In a study that assessed suicidal ideation and attempts as a combined variable, being non-heterosexual significantly predicted suicidality (30).
Suicides
No risk or protective factors for completed suicides were reported.
Self-harm
Two studies assessed risk and protective factors for self-harm behavior, while others focused on self-harm thoughts, or a combination of self-harm thoughts and behaviors. Female international students reported higher self-harm rates than males in two studies; 17.6% vs. 16.1% (statistically significant) (44) and 4.5% vs. 2.0% (not tested for significance) (34). Furthermore, significantly more female than male students endorsed an item asking if they have engaged in and/or thought about self-harm (28). One study found that international students who engaged in self-harm had significantly higher scores on depression, anxiety, stress, and experiences of abuse (and associated distress) than those who had not self-harmed (34). Loneliness and perceived discrimination were significantly associated with greater odds of self-harm thoughts, while the following covariates were not associated: gender, age, relationship status, mask-wearing, and being Asian (38).
Discussion
This review examined the prevalence of, and risk and protective factors for, suicidal thoughts and behaviors in international students. A total of 24 studies were included with the majority published since 2013. Nineteen studies reported data on suicidal ideation, six reported on suicide attempts, and seven addressed self-harm. No studies reported on suicide deaths. In terms of quality appraisal, the studies scored moderate to high on the CAQQS, suggesting that the data quality is acceptable. However, the current review highlights shortcomings in research on suicide-related thoughts and behaviors among international students, including a lack of studies and diverse methodologies leading to inconsistent findings.
Key findings
The prevalence rates of suicidal ideation, attempts and self-harm varied depending on the instruments used, the measurement timeframe, and the nature of the sample. With the exception of international students presenting at a psychiatry clinic (24), rates of suicidal ideation (5.4-28.6%), suicide attempts (1.2%-7.5%), and self-harm (4.8%-17.2%) across timeframes, populations and measures were similar to rates from general college populations (50). Suicidal ideation intensity was typically low among international students, but the inclusion of cases without suicidal ideation may have positively skewed results.
Specific comparisons between international and domestic students produced mixed results. International students reported lower rates, but similar intensity of suicidal ideation compared to domestic students. In contrast, international students displayed a higher prevalence of suicide attempts than their domestic counterparts. Self-harm rates were similar in domestic and international students.
Similar to prior research on common stressors for international students (7), factors related to social isolation emerged as a common risk factor for suicidal ideation. This aligns with the Interpersonal Theory of Suicide (49), which proposes that thwarted belongingness, encompassing various elements related to social connectedness and the need to belong, is strongly related to suicidal thoughts and behaviors. Surprisingly, family connectedness was positively linked to increased suicidal ideation, contrasting with other social connectedness variables. This might be due to the distance from family networks during international studies, suggesting that factors related to social connectedness and isolation are not a homogenous group. More research is required to determine which factors relate to suicidal ideation and the time of their impact, with longitudinal studies needed to establish causality in these relationships.
Other significant risk factors for suicidal ideation encompass comorbid mental health conditions like depression and anxiety, contextual stressors such as experiences of racism and academic stress, along with inadequate coping abilities. These risk factors bear similarities to those observed in other student populations and provide potential opportunities for targeted intervention strategies. An emerging risk factor from the recent years was COVID-19 related stressors (21). International students are a population whose mental health was particularly impacted by COVID-19 restrictions (51), and the present review shows that COVID-19 related stressors are also specifically linked to suicidal thoughts and behaviors. As such, suicide prevention strategies for international students need to incorporate these common risk factors, including potential past and ongoing impacts of the COVID-19 or other pandemics.
The only significant risk factor for suicide attempts was high perceived public stigma. Given that suicidal ideation and attempts are closely related concepts, it may be that risk and protective factors for ideation are also applicable to attempts. However, more research is needed to confirm this. Risk factors for self-harm included identifying as female and common mental health symptoms like depression and anxiety. However, each of these were tested within individual studies so further evidence substantiating these associations is needed. Future studies should also differentiate self-harming behavior from thoughts of self-harm.
Measurement issues in the literature
Various measurement tools and timeframes were used for suicidal ideation, attempts, and self-harm, as well as risk and protective factors. This diversity introduced complexity in synthesizing and comparing research findings. Some studies also measured certain outcomes but did not report them. Furthermore, in several studies (28, 30, 35), the outcome measures were worded in a way that made it impossible to distinguish between different suicide or self-harm related outcomes, for example, using questions like “Have you considered or attempted suicide?” (Yes/No). As such, these studies could not be included in our synthesis of prevalence rates or risk and protective factors. Future studies should use validated assessment tools that clearly differentiate between suicidal ideation, suicide attempts, and self-harming behaviors (52).
When reporting the intensity of suicidal ideation, studies presented average scores on various instruments. These average scores were often low due to most participants in the sample reporting no ideation. Because the average score is skewed by the large number of zero scores, it is impossible to discern if the participants who scored above zero reported low or high levels of ideation. Future studies should consider reporting suicidal ideation data for only those who scored above zero to better capture intensity for those experiencing suicidal thoughts. Addressing these limitations would facilitate an improved understanding of suicidal thoughts and behaviors in international student cohorts.
Implications and future directions
This review showed consistent evidence for social connectedness as a protective factor against suicidal ideation. Promoting social connectedness is already part of university-wide suicide prevention frameworks (53). However, tailored approaches may be required for international students given that they are separated from their social support networks from their home country and may struggle to make new connections due to language barriers or cultural differences (54). Students’ sense of connectedness can be improved by socializing with co-nationals and other international students (54), and as such, universities should continue investing in social activities designed to help international students connect with peers.
Similarly, our review identified common mental health concerns like depression and anxiety as risk factors for suicidal thoughts and behaviors. Access to mental health care is imperative in reducing these symptoms and subsequently lowering the risk of suicide (55). However, it is well-documented that international students underutilize mental health services despite needing them (11). Evidence suggests there are multiple barriers to service access for international students, including low mental health literacy, a lack of culturally appropriate or accessible services, and high costs (13). These are all areas for improved prevention. For instance, international students are often unaware that mental health support is covered by their health insurance, which may be a barrier to help-seeking due to the assumed cost of services (56). International student offices and insurers should ensure that students stay adequately informed about the extent of their mental healthcare cover. Furthermore, mental healthcare pathways for international students should be streamlined across universities, community psychological services and emergency departments (12).
None of the studies included in this review reported on suicide deaths in international students. It is recommended that educational institutions adopt a specific reporting framework for international student suicides (57). Quantifying the rates of suicide mortality is imperative for tracking the scope of the issue on local and global scales, and guiding prevention efforts, as they can provide direct insight into potential causal factors in in such deaths (11, 58).
Additionally, the literature rarely reported the length of time international students have spent in the host country. There is evidence that being new to the country is associated with elevated suicide risk; a coroner’s investigation into international student suicides in Victoria, Australia found that almost half of individuals that took their lives had been in the host country for less than two years (12). Therefore, future studies should investigate the effect of time spent in the host country on suicide-related outcomes.
Future research should explore suicide-related outcomes among diverse international student subgroups to enhance the generalizability of findings, as the current studies have limited representation of countries and ethnicities. International students are a heterogeneous population, and such comparisons are essential. There is preliminary evidence suggesting potential subgroup differences, particularly that Asian international students report higher rates of suicidal ideation, attempts, and self-harm than other international students (40, 44).
There is currently no evidence on effective suicide prevention initiatives for the international student populations (13). However, based on the findings on risk and protective factors from this review, we suggest that emphasis should be placed on promoting social connectedness and improving student mental health via better access to psychology services. Combatting stigma and discrimination that international students experience and managing academic and general life stress are also areas for prevention. Generally, suicide prevention efforts will be most effective when undertaken collaboratively across educational institutions, mental health services, government, and other organizations relevant to international students (13). It is also essential to involve international students and those who work closely with them in designing and implementing suicide prevention initiatives (56).
Strengths and limitations
To authors’ knowledge, this is the first publication to summarize the rates of suicidal ideation, attempts and self-harm in international students across the existing body of literature. Furthermore, this review describes prominent risk and protective factors for suicidal thoughts and behaviors in international students and highlights gaps for future research in this area.
The main limitation of this review is that currently there is not enough available data to draw any major conclusions regarding prevalence rates or factors contributing to suicidality in this student group. It was also not possible to conduct a meta-analysis to quantify the available data due to the diverse range of measures in the primary studies. In line with this, the available literature had varying measures of suicidal thoughts and behaviors, and varying overall methodology, meaning that the quality of data may vary between studies. Finally, it is possible that some studies relevant to this review were not captured by our search strategy.
Conclusion
This review describes the prevalence rates, and risk and protective factors, for suicidal ideation, attempts, and self-harm in international students. Overall, there is little literature on this topic, limiting our ability to draw conclusions. However, in general, the literature suggests that international students may experience similar rates of suicidal ideation and self-harm, and higher rates of attempts compared to domestic students. Key risk factors include social isolation, intrapersonal factors (e.g., depression, anxiety), and contextual factors (e.g., perceived discrimination). More high-quality research featuring robust measurement is needed to adequately capture the prevalence of suicide-related outcomes in international students. Future research can also focus on subgroup comparisons within international students, and comparisons with domestic students. Risk and protective factors should be investigated further, particularly via longitudinal designs to establish causal relationships. Finally, this review provides directions for suicide prevention initiatives for international students, focusing on promoting social connectedness, improving student mental health, and investing in accessible and culturally sensitive mental health care. Given that international students comprise a significant portion of tertiary students worldwide and experience substantial levels of suicidal thoughts and behaviors, it is important that they receive targeted, appropriate, and effective support.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material. Further inquiries can be directed to the corresponding author.
Author contributions
MV: Formal analysis, Investigation, Writing – original draft, Writing – review & editing, Data curation. ML: Project administration, Resources, Writing – review & editing. JR: Conceptualization, Funding acquisition, Writing – review & editing. SM: Conceptualization, Data curation, Funding acquisition, Investigation, Methodology, Project administration, Writing – review & editing.
Funding
The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2024.1358041/full#supplementary-material
References
1. World Health Organization. Suicide (2021). Available online at: https://www.who.int/news-room/fact-sheets/detail/suicide.
2. Australian Institute of Health and Welfare. Suicide & self-harm monitoring (2022). Available online at: https://www.aihw.gov.au/suicide-self-harm-monitoring/data/suicide-self-harm-monitoring-data.
3. Centers for Disease Control and Prevention & National Center for Injury Prevention and Control. Centers for disease control and prevention. In: Suicide Data and Statistics (Atlanta, USA: Centers for Disease Control and Prevention) (2023). Available at: https://www.cdc.gov/suicide/suicide-data-statistics.html.
4. Mortier P, Auerbach RP, Alonso J, Bantjes J, Benjet C, Cuijpers P, et al. Suicidal thoughts and behaviors among first-year college students: results from the WMH-ICS project. J Am Acad Child Adolesc Psychiatry. (2018) 57:263–273.e1. doi: 10.1016/j.jaac.2018.01.018
5. Organization for Economic Co-operation and Development. Education at a Glance 2020. Paris, France: Organization for Economic Co-operation and Development (2020).
6. UNESCO Institute for Statistics. Internationally mobile students - Definition (2023). Available online at: https://uis.unesco.org/en/glossary-term/internationally-mobile-students.
7. Khanal J, Gaulee U. Challenges of international students from pre-departure to post-study: A literature review. J Int Students. (2019) 9:560–81. doi: 10.32674/jis.v9i2.673
8. Zhang J, Goodson P. Predictors of international students’ psychosocial adjustment to life in the United States: A systematic review. Int J Intercultural Relations. (2011) 35:139–62. doi: 10.1016/j.ijintrel.2010.11.011
9. Minutillo S, Cleary M, Hills AP, Visentin D. Mental health considerations for international students. Issues Ment Health Nurs. (2020) 41:494–9. doi: 10.1080/01612840.2020.1716123
10. Xiong Y, Yang L. Asian international students’ help-seeking intentions and behavior in American Postsecondary Institutions. Int J Intercultural Relations. (2021) 80:170–85. doi: 10.1016/j.ijintrel.2020.11.007
12. Jamieson A. Findings into Death of Nguyen Pham Dinh Le. Victoria, Australia: Coroners Court of Victoria (2021). Available at: https://www.coronerscourt.vic.gov.au/sites/default/files/2021-01/Nguyen_186222.pdf.
13. McKay S, Veresova M, Bailey E, Lamblin M, Robinson J. Suicide prevention for international students: A scoping review. Int J Environ Res Public Health. (2023) 20:1500. doi: 10.3390/ijerph20021500
14. Black MH, Scott M, Baker-Young E, Thompson C, McGarry S, Hayden-Evans M, et al. Preventing suicide in post-secondary students: a scoping review of suicide prevention programs. Eur Child Adolesc Psychiatry. (2023) 32:735–71. doi: 10.1007/s00787-021-01858-8
15. Bowden M, McCoy A, Reavley N. Suicidality and suicide prevention in culturally and linguistically diverse (CALD) communities: A systematic review. Int J Ment Health. (2020) 49:293–320. doi: 10.1080/00207411.2019.1694204
16. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Rev. (2015) 4. doi: 10.1186/2046-4053-4-1
17. Rodgers M, Sowden A, Petticrew M, Arai L, Roberts H, Britten N. Testing methodological guidance on the conduct of narrative synthesis in systematic reviews: effectiveness of interventions to promote smoke alarm ownership and function. Evaluation. (2009) 15:47–71. doi: 10.1177/1356389008097871
18. Covidence Systematic Review Software. Veritas Health Innovation. Melbourne, Australia, Veritas Health Innovation (2023).
19. Kmet LM, Cook LS, Lee RC. HTA Initiative # 13: Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields, Alberta Heritage Foundation for Medical Research: Alberta, Canada. (Alberta, Canada: Alberta Heritage Foundation for Medical Research) (2004).
20. McHugh ML. Interrater reliability: the kappa statistic. Biochem Med. (2012) 22:276–82. doi: 10.11613/issn.1846-7482
21. Ahorsu DK, Pramukti I, Strong C, Wang H-W, Griffiths MD, Lin C-Y, et al. COVID-19-related variables and its association with anxiety and suicidal ideation: differences between international and local university students in Taiwan. Psychol Res Behav Manage. (2021) 14:1857–66. doi: 10.2147/PRBM.S333226
22. Bi K, Yeoh D, Jiang Q, Wienk MNA, Chen S. Psychological distress and everyday discrimination among Chinese international students one year into COVID-19: a preregistered comparative study. Anxiety Stress Coping. (2022) 36(6):1–16. doi: 10.1080/10615806.2022.2130268
23. Goodwill JR, Zhou S. Association between perceived public stigma and suicidal behaviors among college students of color in the U.S. J Affect Disord. (2020) 262:1–7. doi: 10.1016/j.jad.2019.10.019
24. Hong V, Busby DR, O’Chel S, King CA. University students presenting for psychiatric emergency services: Socio-demographic and clinical factors related to service utilization and suicide risk. J Am Coll Health. (2022) 70:773–82. doi: 10.1080/07448481.2020.1764004
25. Jun HH, Wang KT, Suh HN, Yeung JG. Family profiles of maladaptive perfectionists among Asian international students. Couns Psychol. (2022) 50:649–73. doi: 10.1177/00110000221089643
26. King N, Rivera D, Cunningham S, Pickett W, Harkness K, McNevin SH, et al. Mental health and academic outcomes over the first year at university in international compared to domestic Canadian students. J Am Coll Health: J ACH. (2021) 71(9):1–10. doi: 10.1080/07448481.2021.1982950
27. Kivelä L, Mouthaan J, van der Does W, Antypa N. Student mental health during the COVID-19 pandemic: Are international students more affected? J Am Coll Health. (2022) 14:1–9. doi: 10.1080/07448481.2022.2037616
28. Li M, Su H, Liao Z, Qiu Y, Chen Y, Zhu J, et al. Gender differences in mental health disorder and substance abuse of chinese international college students during the COVID-19 pandemic. Front Psychiatry. (2021) 12:710878. doi: 10.3389/fpsyt.2021.710878
29. Low YS, Bhar SS, Chen WS. Moderators of suicide ideation in Asian international students studying in Australia. Aust Psychol. (2023) 58:169–78. doi: 10.1080/00050067.2022.2148514
30. Maffini CS. Campus safety experiences of Asian American and Asian international college students. Asian Am J Psychol. (2018) 9:98–107. doi: 10.1037/aap0000087
31. Nadareishvili I, Syunyakov T, Smirnova D, Sinauridze A, Tskitishvili A, Tskitishvili A, et al. University students’ mental health amidst the COVID-19 pandemic in Georgia. Int J Soc Psychiatry. (2022) 68:1036–46. doi: 10.1177/00207640221099420
32. Nguyen MH, Le TT, Nguyen HKT, Ho MT, Thanh Nguyen HT, Vuong QH. Alice in suicideland: Exploring the suicidal ideation mechanism through the sense of connectedness and help-seeking behaviors. Int J Environ Res Public Health. (2021) 18:3681. doi: 10.3390/ijerph18073681
33. Perez-Rojas AE, Choi N-Y, Yang M, Bartholomew TT, Perez GM. Suicidal ideation among international students: The role of cultural, academic, and interpersonal factors. Couns Psychol. (2021) 49:673–700. doi: 10.1177/00110000211002458
34. Rosenthal DA, Russell J, Thomson G. The health and wellbeing of international students at an Australian university. Higher Educ. (2008) 55:51–67. doi: 10.1007/s10734-006-9037-1
35. Sanci L, Williams I, Russell M, Chondros P, Duncan AM, Tarzia L, et al. Towards a health promoting university: descriptive findings on health, wellbeing and academic performance amongst university students in Australia. BMC Public Health. (2022) 22:2430. doi: 10.1186/s12889-022-14690-9
36. Servaty-Seib HL, Lockman J, Shemwell D, Reid Marks L. International and domestic students, perceived burdensomeness, belongingness, and suicidal ideation. Suicide Life-threatening Behav. (2016) 46:141–53. doi: 10.1111/sltb.12178
37. Taliaferro LA, Muehlenkamp JJ, Jeevanba SB. Factors associated with emotional distress and suicide ideation among international college students. J Am Coll Health: J ACH. (2020) 68:565–9. doi: 10.1080/07448481.2019.1583655
38. Um MY, Maleku A, Haran H, Kim YK, Yu M, Moon SS. Mask wearing and self-harming thoughts among international students in the United States during COVID-19: The moderating role of discrimination. J Am Coll Health: J ACH. (2022) 26:1–7. doi: 10.1080/07448481.2022.2103378
39. Wang KT, Wong YJ, Fu C-C. Moderation effects of perfectionism and discrimination on interpersonal factors and suicide ideation. J Couns Psychol. (2013) 60:367–78. doi: 10.1037/a0032551
40. Xiong Y, Pillay Y. A national study of the mental health status of Asian international students in the United States. J Multicultural Couns Dev. (2022) 51:82–91. doi: 10.1002/jmcd.12238
41. Yang B, Clum GA. Life stress, social support, and problem-solving skills predictive of depressive symptoms, hopelessness, and suicide ideation in an Asian student population: A test of a model. Suicide Life-Threatening Behav. (1994) 24:127–39. doi: 10.1111/j.1943-278X.1994.tb00797.x
42. Yang B, Clum GA. Measures of life stress and social support specific to an Asian student population. J Psychopathol Behav Assess. (1995) 17:51–67. doi: 10.1007/BF02229203
43. Yeung TS, Hyun S, Zhang E, Wong F, Stevens C, Liu CH, et al. Prevalence and correlates of mental health symptoms and disorders among US international college students. J Am Coll Health: J ACH. (2022) 70:2470–5. doi: 10.1080/07448481.2020.1865980
44. Zhou X, Zhou AQ, Sun X. Prevalence of common mental concerns and service utilization among international students studying in the U.S. Counselling Psychol Q. (2022) 35:483–502. doi: 10.1080/09515070.2021.1875400
45. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary care evaluation of mental disorders. Patient Health Questionnaire. JAMA. (1999) 282:1737–44. doi: 10.1001/jama.282.18.1737
46. Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. (2011) 168:1266–77. doi: 10.1176/appi.ajp.2011.10111704
47. Beck AT, Steer RA, Ranieri WF. Scale for Suicide Ideation: Psychometric properties of a self-report version. J Clin Psychol. (1988) 44:499–505. doi: 10.1002/(ISSN)1097-4679
48. Rudd MD. The prevalence of suicidal ideation among college students. Suicide Life-Threatening Behav. (1989) 19:173–83. doi: 10.1111/j.1943-278X.1989.tb01031.x
50. Mortier P, Cuijpers P, Kiekens G, Auerbach RP, Demyttenaere K, Green JG, et al. The prevalence of suicidal thoughts and behaviors among college students: a meta-analysis. psychol Med. (2018) 48:554–65. doi: 10.1017/S0033291717002215
51. Riboldi I, Capogrosso CA, Piacenti S, Calabrese A, Lucini Paioni S, Bartoli F, et al. Mental health and COVID-19 in university students: findings from a qualitative, comparative study in Italy and the UK. Int J Environ Res Public Health. (2023) 20:4071. doi: 10.3390/ijerph20054071
52. Batterham PJ, Ftanou M, Pirkis J, Brewer JL, Mackinnon AJ, Beautrais A, et al. A systematic review and evaluation of measures for suicidal ideation and behaviors in population-based research. psychol Assess. (2015) 27:501. doi: 10.1037/pas0000053
53. MacPhee J, Modi K, Gorman S, Roy N, Riba E, Cusumano D, et al. Strengthening safety nets: A comprehensive approach to mental health promotion and suicide prevention for colleges and universities. NAM Perspect. (2021). doi: 10.31478/namperspectives
54. Smith RA, Khawaja NG. A review of the acculturation experiences of international students. Int J Intercultural Relations. (2011) 35:699–713. doi: 10.1016/j.ijintrel.2011.08.004
55. Bear HA, Edbrooke-Childs J, Norton S, Krause KR, Wolpert M. Systematic review and meta-analysis: outcomes of routine specialist mental health care for young people with depression and/or anxiety. J Am Acad Child Adolesc Psychiatry. (2020) 59:810–41. doi: 10.1016/j.jaac.2019.12.002
56. Orygen. International Students and Their Mental and Physical Safety. Victoria, Australia: Orygen (2020).
57. Council of International Students Australia. Council of International Student Australia’s Productivity Commission Recommendations (2019). Available online at: https://www.pc.gov.au/:data/assets/pdf_file/0015/251142/sub893-mental-health.pdf.
Keywords: international students, suicide, suicide prevention, self-harm, risk factors, protective factors, systematic review
Citation: Veresova M, Lamblin M, Robinson J and McKay S (2024) A systematic review and narrative synthesis of prevalence rates, risk and protective factors for suicidal behavior in international students. Front. Psychiatry 15:1358041. doi: 10.3389/fpsyt.2024.1358041
Received: 20 December 2023; Accepted: 28 February 2024;
Published: 14 March 2024.
Edited by:
Fabia Morales-Vives, University of Rovira i Virgili, SpainReviewed by:
Ilaria Riboldi, University of Milano-Bicocca, ItalyJin Han, New York University Shanghai, China
Copyright © 2024 Veresova, Lamblin, Robinson and McKay. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Maria Veresova, bWFyaWEudmVyZXNvdmFAb3J5Z2VuLm9yZy5hdQ==