When Nancy Theis' son was missing for three days, she says, she never imagined he was in their Webster home with her and her husband the whole time. But Theis' son was upstairs in the attic, dead. He had shot himself.

"The idea of anyone in my family committing suicide, much less my son, never once came into my mind," Theis says. "As a mother, it destroyed my innocence."

Whether her son's suicide could have been prevented is something Theis says she can't answer.

"That's the million dollar question, isn't it?" she says. "That, and why?"

Suicide is the 11th leading cause of death in the US. But, until recently, what we knew about it was largely derived from studies about completed suicides. Earlier this year, researchers at the UR's Center for the Study and Prevention of Suicide began looking at how college students cope with stress for clues to what causes some people to take their own life.

The UR, along with five other universities --- Cornell, MIT, Columbia, Princeton, and Harvard --- provided all their undergraduate students with a survey that asked questions about health, lifestyle, and how they coped with the pressures of college. More than 1,300 UR students responded to the Student Well-Being Survey: about 33 percent of the university's undergraduates. The results from all six universities are still being analyzed.

Suicide prevention is not a new idea. Hotlines, for example, have been available in many major US cities for decades. But the approach to prevention is changing. Researchers like those at the UR want to know whether suicide-prevention programs could be modeled after those initiated 25 years ago for cardiovascular disease, which have been successful in educating the public and helping to reduce mortality rates.

"The unfortunate thing about suicide prevention is that someone who is suicidal generally doesn't walk into a clinic seeking help from a psychologist," says Kerry Knox, associate professor of psychiatry and community preventive medicine at the UR. "It happens, but not usually. So up until the last 10 years, we were unable to provide help until they were in the emergency room after they attempted. From a public-health standpoint, we want to know if we can provide help way before that point, because obviously that's when the help is needed."

Knox is one of the lead researchers on the NIH-funded Student Well-Being Survey. The stigma associated with suicide has been a major obstacle in prevention and treatment, she says.

"It's kind of strange, because society has a tendency to punish people for doing the right thing and admitting they have a problem and seeking help," she says. "It's pretty difficult to help someone if they are too intimidated about coming forward. Often there are repercussions in our society for men who are perceived to be weak or somehow emotionally unstable."

Knox was a lead researcher in an earlier UR study looking at suicide and its prevention in the US Air Force following an alarming increase in suicides among service personnel during the 1990's. That landmark study, first reported in the British Medical Journal in 2003, analyzed data on active-duty personnel collected by the Air Force from 1990 to 2000.

"In 1995, the head of the Air Force was seeing as many as one suicide a week," says Knox. "He had read all of the cases that had come across his desk. Substance abuse was also a problem, and he wanted to know if there was some way to catch these people early before their problems caused them to make this kind of a decision."

An extensive program was put into place that emphasized community awareness, group discussions, and "de-stigmatization." The central message: seeking help for a mental-health problem was not a sign of weakness. Knox described it as a significant cultural shift for the Air Force.

"This was an entirely different dynamic that was very hard for many of these men at first, because they feared that seeking help would limit their career opportunities in the service," says Knox. "We had to reassure them that not seeking the help they needed is what would limit their careers. It is a sign of strength and leadership to seek help."

The program went one step further. People from everyday life, the people who most often came into contact with active-duty personnel, were trained as "gatekeepers." The gatekeeper's job was to recognize changes in behavior: depression, detachment, change in habits, isolation, giving away personal belongings, or self-medication through drugs and alcohol. The gatekeepers were also trained to listen for conversations that included references to suicide and death. When changes were observed, the gatekeeper intervened and helped find counseling.

Knox says the Air Force observed a significant and sustained drop in suicide rates following the program. And it served as the first real demonstration for preventing suicide based on a community-wide approach to improving overall mental health. The Air Force research helped to change the view that suicides tend to be related to specific events, so-called "triggers." Emotional losses --- job lay-offs, foreclosures, divorces, deaths --- have long been referenced as triggers for suicide. But researchers like Knox point to the presence of underlying psychological problems. People already weakened by mental illness are more vulnerable when faced with such losses. Depression, personality disorders, post traumatic stress, and severe anxiety are some of the real culprits.

Knox says she expects the Air Force study to be just as relevant today as more veterans return home from the Iraq War with severe emotional problems.

On the fourth floor of Dewey Hall, a doorway leads to a small waiting room. It's a plain, unassuming room with a few chairs and a receptionist's desk. But it's an area of the UR campus where some students and faculty are reluctant to be seen entering or leaving. It is the University Counseling Center.

"Depression is a major concern," says Linda Dudman, the UR's associate director of health promotion. "We also see related health issues such as eating disorders, alcohol and substance abuse, and of course sexual health. But in order for students and faculty to take advantage of the services we offer, they have to have that sense of trust and security. They are just as concerned about their privacy as they are about the problem they may be experiencing."

The UR employs a full-time team of nurses, counselors, and licensed psychologists for students and faculty to turn to for help. The UR is also applying the lessons learned from its own research: student Residential Advisors have been trained as gatekeepers.

"It's a brilliant concept," says Daniel Watts, the UR's associate director for residential life and assistant dean of freshmen. "When a student is in crisis or headed for crisis, who is there? Who is seeing this and is in the best position to help that student get help?"

The UR's Residential Advisors are paid positions, and the competition for them is strong. Watts receives about 150 applications a year. About 40 students are accepted and go through seven weeks of training, and learning how to become a gatekeeper is part of that training.

"It's kind of like boot camp," says Watts, "but we feel it is extremely important, because they are the foundational part of this community. And I can tell you that if you ask any RA what keeps them up at night, they'll answer, ‘Something horrible happening, like someone dying or committing suicide.' It's their worst fear."

(Over this past weekend, one UR student did commit suicide, and according to the Campus Times, another had threatened to take his own life the previous week. The UR's dean of students, Jody Asbury, said on Tuesday that the university has sent letters to students, staff, faculty, and parents about the suicide. And there have been a series of meetings discussing the need to seek support and detailing the services the UR offers.)

The advisors are trained in a technique Watts refers to as QPR: "question, persuade, and refer."

"The RA's are not counselors," says Watts. "They are not doing therapy. But if they see that someone is having difficulty, they know how to ask the delicate question: ‘How are you doing?' And they explain what kinds of help are available, tell them it is in their best interest to check it out, and they stand with them to reassure them they are making the right decision."

Watts says he tells the RA's that they should never promise confidentiality but that they can promise privacy, and the two are not in conflict with one another.

"If the RA is having a problem, like let's say they are unsure of what they may be seeing, they come to us [supervisors] for guidance," he says. "The RA is never out there alone. We have three layers of supervision, including 24-hour, on-call support for whatever the problem may be. But it's also important for students to know that we are a body of rules. There are consequences. We care for you, but if you're not well, if you're suicidal, we're not a treatment center. You need to get help. Sometimes we need to say, ‘You're not ready to be here.'"

Christelle Domercant, a junior at the UR, is a student advisor and went through the gatekeeper training.

"I look for certain changes in behavior and changes in mood," she says. "Sadness, hopelessness, anxiety about grades: we all have some of this occasionally, because there is a lot of pressure."

And Domercant says she uses the training all the time. Suicide is not something she worries about, but she doesn't let her guard down, either.

"I've actually asked one of my friends that question, and she responded pretty well to my concerns," she says. "Fortunately, she was not suicidal, but I think she understood my reasons for asking. There is so much pressure, and it gets worse. I think the junior year is the hardest, because you're in the middle and now you have to start making decisions. What are you going to do now? Are you going to try to get a job, or are you going to go to graduate school? If so, where? It's just a lot of pressure to make the right decision."

Students do experience the stress of competition to get into school, says Linda Dudman, and there is an adjustment period for students who have never been away from home. But she agrees that the stress gets worse in the junior and senior years.

"For a lot of students, it is really hard when they see their friends making plans for the future," she says. "It really is upsetting to some students, especially those that have reached their junior or senior year, and they just don't know what they want to do. Or worse, they have discovered that they have earned a degree in something that they don't like. That's when we've seen some students really run into trouble."

College campuses are among the safest environments in the country, says Allan J. Schwartz, a clinical psychologist and associate professor of psychiatry at the UR.

"If you are the parent of a young male living in an urban environment, you should be reassured that if your son is in college, he is probably safer than he could be in almost any other situation," says Schwartz. "Suicide among students is half that of the general population. And that has to do with one thing: firearms. You just don't have an abundance of firearms on most college campuses. Firearms are the leading method for committing suicide by both men and women. It cannot be overstated. The point that firearms are so overwhelmingly linked to suicide means that if we are serious about preventing it, we need to do something about their availability."

The ability to prevent suicides is still an open question for Schwartz, partly because access to mental-health services is not readily available for all Americans. And 100 years after Sigmund Freud set the groundwork for psychoanalysis, Americans still have a tepid relationship with psychology.

"We know, for example, five out of six students who have committed suicide had no prior contact with counselors," he says. "That certainly supports the relevance of students as gatekeepers. But there are other things at work here. Emotional illnesses have been equated with moral shortcomings. People don't like to admit they need help, because they don't want to think of themselves as unwell in any way, and they will do what they can to prevent others from thinking it as well."

Schwartz says the data on suicide shows that women make more attempts to commit suicide than men. But men commit suicide four times more often than women, and middle-age to elderly men are even more likely to commit suicide.

But if suicide is a greater risk for older men, why are the colleges studying young students?

Knox says by studying student attitudes and how they respond to difficult situations early in life, researchers may see "markers" for how they cope with problems later in life.

"We're looking for better intervention and training techniques," she says. "We've always known there is a connection between the mind and the body, mental health and physical health. But now we are beginning to see more clearly the different ways that mental-health issues manifest themselves. There is even a debate in the research community about the definition of suicidal behavior. Some people think that it includes behaviors like self-cutting, eating disorders, and binge drinking."

More than 22 years after her son's death, Nancy Theis says she still has days when she is angry at him. About a year after he committed suicide, she co-founded After Suicide with two other women. After Suicide is a peer support group for survivors that meets twice a month at the Al Sigl Center. That year, she says, four other young men from the Webster area committed suicide.

"It just goes to show it's more common than most people think," says Theis. "But you won't hear about it, because this is a subject you can't talk to anyone about. It's just not polite conversation. Some people think it's a sin. Some people think it's a crime. Others look at you and think you must have done something wrong, like you're a bad parent or a bad husband. The stigma and the shame cause people to not talk about it and not see it. It's like a disease, but it's not the same as a death from cancer or heart disease. People are much more sympathetic in those situations."

Over the last 20 years, Theis says, more than 2,000 people have joined the group. Some come once or twice and leave. Others come for years. Some only show up for specific dates like anniversaries and birthdays. More than half of the people who attend are parents of people who committed suicide.

"It's as if they need to tell their story over and over again in order for them to understand what has happened to them," she says. And Theis says she and her husband didn't understand what had happened to them, either. "People have a tendency to think, Oh, you'll get over it in a few weeks or a month. But no, you don't. You never get over it. It's like your life is divided into two parts. There was the time before it happened, and the time after."

Many people, Theis says, knew that their loved one was experiencing mental health problems and were trying desperately to help them.

"But you can run out of resources," she says. "Maybe they've been hospitalized, but the insurance has run out and the hospital has sent them home with a few prescriptions. Prevention just eludes some people."