tags: suicide, mental health, bipolar disorder, depression, anxiety, college, university
Approximately 1,300 college students will commit suicide this year, according to experts. Yet even though university students are less likely than other age and occupational groups to take their own lives, suicide has increased recently on campuses and it is the second-leading cause of death among college students. Why?
"We have had an increasing number of students with serious mental health problems while services are lacking," observed UC Santa Barbara Vice Chancellor Michael Young, co-chairman of the Student Mental Health Committee. "We just don't have the appropriate level of support to have healthy campuses."
The increase in mental health problems in the UC system is not unusual; it reflects a national trend. Increasing stress levels combined with growing numbers of students who are already under the care of a mental health professional lie at the heart of this problem.
"There are more troubled kids, that's the bottom line," said Elizabeth Downing, who heads the UC Santa Barbara health center. "We boomer generation parents have not done a good job in a way. We were so laid back. Now there's so much stress. I think we've done our children a great disservice. They are driven in every part of their lives."
In the UC system, 25% of students seeking counseling are already on psychotropic medications. Many are being treated for depression and anxiety, some for bipolar disorder. Additionally, at UC Berkeley, 45% of students surveyed in 2004 reported suffering an emotional problem in the previous 12 months that significantly affected their wellbeing or academic performance. Nearly 10% said they had seriously contemplated suicide. One decade ago at UC Santa Barbara, an average of 21 students came to the counseling center each quarter because they were experiencing an emotional crisis. Now, more than 200 students a quarter come for help, saying they are in a crisis.
"Our crises have gone way up and we have fewer psychologists to deal with that," said Jeanne Stanford, director of counseling services. "We feel like we have become a crisis center."
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How many of these suicide victims on drugs? How many jumped out a window because they thought they could fly?
Must be nice, having a crisis center. Some schools will expel a student who seeks suicide counseling rather than risk legal liability.
Universities are extremely high-strung, tension-filled, stressful places... for everybody. The reasons vary, but there are probably common causes; a lot of it probably comes from constant reminders of high expectations of "excellence," where the sort of excellence sought depends on who you're talking to. For students, it's not only the sense that you have to get very high grades if you're going to "succeed" in life, but also that you have to meet all sorts of social expectations.
It'd be nice if we could turn down the intensity a little.
-Rob
As a current undergrad student, I just thought I'd toss an anecdote in here: my university has one of the highest rates of eating disorders in the nation, and our counseling center refuses to treat them, period. They claim that it is a longer "therapeutic investment" than they are willing to make, and that the counseling services are supposed to be for "short-term issues". In other words, EDs are definitely not quick-fixes, so they choose not to deal with them. They claim they will "refer you to the community resources", which means that they tell you to call your insurance company and find a private practice provider in your area.
When you do that, you discover that there are no psychologists within 45 miles that accept ED clients. (I don't understand this at all, I would have assumed that people would capitalize on the potential market for these cases in a college town, but then again I know that many therapists prefer not to treat ED cases because of the high relapse rates and medical liability issues).
It takes a LOT of strength to admit to a problem and reach out for help, and it is quite a blow to be rebuffed and left feeling like you have nowhere to turn.
Lighting? This has certainly changed dramatically in recent years, especially in places like college dorms.
http://www.sciencenews.org/articles/20060527/bob9.asp
http://psychcentral.com/blog/archives/2007/04/11/lighting-the-way/
Spectra, from http://www.ledmuseum.org/
Typical new light sources -- light emitted below 500nm is in the band that suppresses the body clock for sleep/melatonin and seems (see above, and below) to affect mood.
LCD computer display --
http://ledmuseum.candlepower.us/eighth/soyomon.gif
Typical compact fluorescent --
http://ledmuseum.candlepower.us/seventh/loacfl1.gif
http://www.psycheducation.org/mechanism/Clock.htm
"... this is just great science!"
Rob Knop:
My great-uncle, Benson Snyder, was the head of MIT's psychological services during the late 1960s. Based on his experiences working there and at Wellesley, he wrote a book called The Hidden Curriculum, in which he argued (among other things) that the intensity is so high that it's just not humanly possible to do everything expected of you! Students, therefore, turn to various ways of "faking it" and develop elaborate schemes of gamesmanship, just to get by.
The suicides at MIT were the main reason that freshman year is pass/fail. That was instituted in the late 1960s, early 1970's, and is still in effect. It has dropped the suicide rate a lot.
I think that most of the stress is self-imposed (at least at MIT). The freshman year is the most dangerous. You have freshmen who were used to being #1 or #2 in their class since kindergarten, and then they go to MIT where half of them are below average? It is a transition a lot of people have difficulty with. Being away from home, caught up in the whirlwind of intellectual activity that is MIT, it can be a challenge, learning to "drink from the firehose" (as the expression goes).
But I think a lot of the problem now is the bullying and meaness that society has developed. The "politics of personal destruction" has had trickle down effects and has made society a harsher and meaner place to try and get by in. It is the mentality of "winning" at any cost, even by lies, tricks, and going negative.
There is far too much importance placed on "hot topics", and what people in "hot fields" think are important. For the most part, we won't know if these "hot fields" are important or not for another 10 or 20 years. Funding is so difficult that lots of good ideas are being thrown away. What happens to the good researchers who can't get funded? How much of that stress trickles down to the students?
N.B. Since the 2002–03 academic year, MIT freshmen have only had one term of pass/fail grading. The fall term is pass/no record (classes the student fails simply don't appear on the transcript) and the spring term is graded A, B, C or No Record.
Pass/no record is an improvement over pass/fail.
In college, my best friend Karen and I wondered why there weren't MORE suicides. I think it's just a stressful environment. You're taken away from everyone and everything you grew up with, you're sharing a tiny room with a total stranger, you're totally unsupervised and accountable to no one but yourself, you're trying to make friends and fit in, and oh yeah, you're keeping up with the demands of several courses too -- structured much differently than in high school.
Plus, there's the whole drug and alcohol factor. During my entire freshman year, I met ONE person who didn't drink and party. He was an upperclassman on anti-seizure meds. I noticed, after I'd gotten into a philosophical drunken mood, that people handle drugs and alcohol differently. I loved drinking because it always made me so happy (who knew walking down the street could be so much fun!) but some people got really depressed and serious when they were drunk.
There's a million ways of not handling the pressure well. Some, like my friend Karen, fail out of school. Some become internet stalkers (I was on the receiving end. That sucked.) Some withdraw from everything. Some act out. I was shocked one night to return to my dorm and see bloody footprints in the stairwell. Curious, I followed them to the fourth floor. There was an increasing amount of blood. I made it all the way to the shattered plate glass windows of the floor lounge and the crimson floor before an RA told me to go back to my room. I heard later that the guy who did it was angry over a breakup and put his fists through the window. He lost a third of his blood, but lived. I wonder, would he have been counted a suicide if he died? I also wonder what becomes of these people. I hope they get help and move on, but not always I guess.
I've read your blog a few tiimes, good stuff.
Anyways, very intersting satistics, but hardly surprising. When I was in USAF we would often have Suicide Pervention briefings, mandatory once a year but held more often than that. They would always show us slides showing the total numbers of suicides for the Air Force that year and show the trends over months and years. And of course it was always the First Term Airmen that would have the highest number of suicides. Those kids fall into the same demographic as the college kids you talked about above, fresh out of high school, away from home for the first time, etc.
Now my questions is this, how common is suicide amongst folks in that age group that go straight to the regular work force, those that don't go military or to college. Are there any studies or info on that? I'd be interested in seeing the relative percentages.
I apologize if I don't make much sense.
As with any complex behavioral question, I very much doubt that there is a single answer -- or even a single predominant answer. I would posit a combination:
1. The problem itself being more open. It used to be that "mental health" problems were more shameful than not, and to class oneself as having one -- or admit that you had one -- was not the done thing, if you could at all help it. Of course, concomitantly with mental health issues becoming less shameful, more things which were just considered one part of "normal" behavior, if not good behavior, were either granted recognition as abnormal, nonfunctional behaviors or openly medicalized.
2. Pressure on more people to "achieve", not just more pressure to achieve? This is tentative; I would need hard data about the cultural trends of who is expected to continue on with university or college, and why.
3. Daedalus2u mentioned the "culture of meanness". Bullying was always common in primary and secondary schools, but I have to agree -- there is now a growing cultural trend of self-absorption where it has become simply amusing to have a go at other people, at older ages and in ways which would have been deemed culturally unacceptable even a couple of decades ago, I think. We live in a culture which has gone back to a very medieval view of regarding people as things rather than individuals like ourselves, with feelings, deserving of courtesy. Courtesy itself has taken a back seat to amusement, in many ways. (Gosh, I really do sound like an old fart myself here, don't I...)
4. Lack of coping skills. There is now at least one generation of kids whose parents have made concerted efforts all their lives to shield them from life's dangers and unpleasantnesses. Kids are shielded from the basic realisations that life IS unfair; that there are always going to be some sort of consequences for what you do and how you do it, and you aren't always going to like those consequences; and yes, you are able to hurt yourself if you do stupid things.
The number of university students my husband and I have dealt with in the last few years who have spent their lives being shielded from the consequences of stupidity and dishonesty is staggering; they have been taught over and over again that they should "feel good about themselves", without being made to make the effort and do things that they could feel good about. They have been passed along from grade to grade in school with minimal effort and almost no understanding; many of them are completely unfamiliar with the concept that if you fail to turn an essay in, or if you turn in your "essay" and it's just a cut-and-paste job from someone's website, then yes, you can and will be failed. Many have a very real sense of entitlement, which has been pandered to consistently for years; to have this entitlement withdrawn and to be confronted with the "unfairness" (please note those quotes) of failure and condemnation for lack of effort, is a nasty shock to the system.
Many, too, have been "let off the leash" for the first time at university. This certainly isn't a new problem -- heck, it's pretty much traditional that people discover that there is now no-one around to stop them from drinking and partying until 4am, and people get sick and hurt. People always get sick and hurt, on their own for the first time. The only difference now from how it used to be, is that now many kids have been protected as much as their parents could from physically hurting themselves when they were younger, by being prevented from running around outside and climbing and jumping off things and fighting and falling. Consequently, their brains never seem to make the connection that "pain hurts -- it is undesireable -- certain physical actions will cause you damage and should be avoided" when they are young, and then when they hit adolescence they become adrenaline junkies without a good sense of how much damage their bodies could or should take. So when the external controls fall away, there is a somewhat wider sector than there used to be of the population who do stupid things and trash themselves...and then don't know how to handle it.
5. A highly sexualised culture, but with almost as many teenagers just as clueless about the real emotional and physical issues which come with sex as there were in the 50s. Sex is great, easy, fun, desireable, everywhere!...Except all the bits about emotional fallout, pregnancy, and STDs that you don't hear about before you end up with something like, because you didn't learn about how to prevent them...
6. Easy credit, high tuition, and a consumer society. It is now easy for a student to be tens of thousands of dollars in debt by the time they hit their third year of university. And that's often about the time that people start realising that they are going to have to pay it back somehow, and they don't know where the money is going to come from.
----
We have a volatile cultural mix, here, and we don't seem to be doing much by way of preparation for it all during pre-university adolescence. A lot of middle-class kids seem to have the status of protected young children right up until they actually hit university, rather than the increasing responsibility that maybe they should have had in the years before.
Just a few of my (old fogeyish) thoughts.
You may sound like an old fart Luna, however you and Daedalus2u have written what I have felt for some time but couldn't put clearly into words.
People do seem to have become more selfish and uncaring of others and the feelings of others over the last couple of decades.
It has washed public & political discourse into the gutter. How to turn the flood?
Now my questions is this, how common is suicide amongst folks in that age group that go straight to the regular work force, those that don't go military or to college. Are there any studies or info on that? I'd be interested in seeing the relative percentages.
Seconded. People keep tossing out the idea of being independent and away from home for the first time as a contributing factor - what's your control group? A little context would go a long way, too - 1,300 suicides out of a total undergraduate population of how many? If it's the second leading cause of death, what's the first, and what's the difference (i.e. is the first leading cause of death 10 times more likely to kill someone, or just 15% more likely)?
Also, all this talk of long-term trends in culture over decades without any supporting evidence is tiresome. That's why it sounds old-fogey-ish: "Back in my day..." I don't know if current culture is "meaner" than that of 15 years ago, I certainly have noticed no such trend, but I haven't really been looking. Does anyone have anything more than anecdotes to support this idea? I grant it's possible, and if true a very interesting (and worrying) phenomenon - but can somebody please provide evidence?
I apologise for having a feeling, also today is my day not yesterday.
It isn't that easy to find data when "meaner" and "selfish" aren't well defined; as I said it is a feeling based on personal experience.
Perhaps it is just the golden glow of memory.
Stung! ;-D
TheBrummell, while I don't have any statistics about meanness to hand, I can provide some links for comparisons between suicide rates amongst students and non-students.
National age-group statistics are available from various reports here:
http://www.cdc.gov/ncipc/osp/data.htm
As noted by people at the University of Washington in 2001:
"Suicide is not uncommon in this age group, according to national statistics. In fact, according to the American Federation for the Prevention of Suicide, U.S. citizens aged 15 to 24 are at a very high risk for suicide. It is the third-leading cause of death for these ages - second for college students.
And 19- to 24-year-olds enrolled in college have a higher suicide rate than non-students. Rates have more than doubled for college-age women since the '50s. For men, the rates are now at about three times those of 50 years ago."
The main leading cause of death in the age group is "unintentional motor vehicle injury" -- in the vast majority of cases, involving alcohol. In the population-at-large for that age group, the second leading cause of death is actually murder, and the third leading cause of death is suicide. Amongst college students specifically, motor vehicle accidents are the leading cause of death and suicide second. You can get an idea of numbers from the CDC statistics as well -- motor vehicle accidents are about 5x more likely than suicide.
It does, however, take a bit of reading around to find studies where fatalities in that age group are analysed as students vs. non-students, and actually, data for what *is* the student-vs.-non-student second leading cause of death seem to vary from place to place and widely between socioeconomic strata. In fact, at least a few studies ("Social Hopelessness and College Student Suicide Ideation" by Heisel, Flett & Hewitt, Archives of Suicide Research, 7:221^235, 2003; and "The Big Ten student study: A 10-year study of suicides on Midwestern university campuses." by Silverman, Meyer, Sloane, Raffel, & Pratt, Suicide and Life-ThreateningBehavior, 27, 2857303, 1997) indicated that the risk of suicide amongst students was about half that of the risk of suicide amongst non-students! So either the risk of student suicide has risen quite a bit in the last 7 years, which is possible and what the Uni of Washington leads me to believe (but I can't find a paper ref for that one) -- or the risk of murder amongst non-students has also risen, which I would also find possible.
So, there -- now you have some hard numbers to chew on, anyway.
Luna_the_cat, excellent, thank you! Very interesting data to chew on.
I apologize for my earlier grumpiness. I did not intend to chastise anyone for having feelings, hunches, impressions, intiutions, or whatnot. Sorry!
A quick first-look at the numbers:
Motor-vehicle 'accidents' are the leading cause of death for both non-students and students aged 19-24, by a large margin. Murder is second for non-students, with suicide third. Suicide is second for students. Students seem to be at less risk of suicide than non-students, a rather counter-intuitive finding given much of the discussion (stress, away from home, etc) above.
So, going to college seems to reduce the risk of death by murder by a large amount, and reduce the risk of suicide by perhaps half. Note this is correlation, NOT causation.
...while I don't have any statistics about meanness to hand...
Indeed, I expect such statistics are very hard to obtain. How would one quantify "meanness"? Are there reasonable data that could be used as proxies? Would those studies of response-times of random passers-by to a researcher pretending to be collapsed on the sidewalk be useful here? The studies I know of always seem to compare large cities to small towns (with predictable results) - have there been longitudinal, long-term studies of this nature?
That LA Times article is being very fuzzy with the data. I was an organizer for the UC Berkeley study and it was not of the entire campus. It wa a survery of graduate students only. You can see the full presented data at:
http://www.ocf.berkeley.edu/~gmhealth/reports/gradmentalhealth_report20…
The article focuses on suicides which are in such small raw numbers (i.e. 0-4 per campus per year) that small bumps are not trends. I'm not sure how much I'd trust any number in that article.
Like Luna_the_cat said, there is minimal, if any, evidence that this is a problem for colleges and not just the age range. Factors like depression and eating disorders may be higher. The real added danger for colleges is that you take 1000-30000 people and pull them out of the family/support structure where they grew up which sometime brings problems to the surface. The good focus on colleges is they are a place where people have a much higher chance of getting professional care if the system works well. If we could drop mental health problems in campuses, it provides a way to help non-students too.
The focus of the UC officials in that article were on lack of funding for counseling. I don't remember the numbers off the top of my head, but at one point the UC Berkeley campus of 30,000 students had ~10 full-time counselors and a few part-time MDs and others. After 5 or 10 in-house sessions students would be farmed out to local health providers and would have to pay a nontrivial amount of money for counseling. Imaging a town fo 30,000 people all in the peak ages for showing serious mental health problems and only 10 people there to help. Since then the health center budget has increased, but I'm not sure how much has changed on the ground.
I have a feeling that there is probably something about trends in bullying and attitudes over several decades, buried in the Social Sciences Index. The problem is, I'm not really a social scientist, and don't have a good enough feel for the right search terms to extract the meat from the depths of the SSI. I could probably find something relevant eventually, but I haven't got the 2-3 hours it might well take.
I was kind of using popular entertainment as a proxy. How much TV derived its "amusement value" from real-life people being absolute sh**s to each other in more-or-less real life situations in the 60s, 70s, 80s, 90s? I mean, now that we have glamorized "reality TV", I actually see people imitating it in real life. And don't get me started on Jerry Springer. Was there something which had that effect in previous years, or is this sort of thing as unique to the late 20th C./early 21st C. as I think? And what about the rise of the "shock jocks", first on radio and now all over the bloody place? They do have an influence on attitudes, including the attitude that it's ok to really rip someone you don't like to shreds if you can get a laugh out of it -- and that goes with audiences more willing to laugh at it.
But I agree, this is anecdote and feeling, not hard data. If I were funded for this kind of research....
I think the increase in meanness is real. I am not sure how to document it though. Once it starts going up, it is going to get worse. There is what is called "the cycle of violence". When people are treated violently and abusively, they tend to become abusive and violent themselves. Somewhat difficult to quantify, and an individual may be able to avoid sinking into that pattern, but the overall trend for large populations is real.
I think the "shock jocks" are part of it, as are the "lock em up and throw away the key" types, criminalizing addictions, the negative political ads, characterizing your political opponents as "traitors", or "terrorist lovers". Blaming 9/11 on gays and lesbians? Huh?
I am not sure if this has been verified, but I suspect that when people are treated violently and abusively as children, either they become abusive and violent toward others, or they beome abusive and violent toward themselves (aka depression and suicidality). I know it isn't "that simple", but look what is happening in Iraq.
Reasons why I think the world has grown meaner.
All is anecdotal, but is based on my experiences.
1) People are treated as commodities.
You are hired to do a job and you know from day one that they will replace you or sack you if they can save a pound, irrespective of your loyalty to the firm.
There used to be an unwritten compact between employer & employed, be loyal to us we'll be loyal to you. That no longer exists, so employees move jobs more often and are under more stress and this leaches out into their families.
Please note; I am a contractor so no such compact is expected by me, but it is sad to see the staffers getting binned after they've been so loyal.
2) Success is measured by how much money you have, this actually isn't new but is much more in your face.
3) Insulting people who don't conform has become almost mandatory. Tolerance is now seen more in the breach.
4) People are more standoffish and seem almost scared to interact with strangers, even in public settings such as pubs.
5) In your face rudness and agression seem to have become fashionable.
I suspect we are returning to the type of society common in the 1700s in Europe.
Devil take the hindmost seems to be the order of the day.
This is especially hard on young people who haven't been allowed to fail suddenly being cast into a competitive world where choices can have dire consequences.
I have a mechanism by which society could be getting meaner, via nitric oxide phsyiology. NO is a plieotropic signaling molecule involved in hundreds or thousands of different physiological pathways, including many involved in ATP regulation. Under conditions of "stress", NO is lowered to release the inhibition of cytochrome c oxidase to allow for maximum generation of ATP via oxidative phosphorylation. There is considerable thought that many of the diseases associated with "stress", are due to low NO caused by that stress.
I think that the "desperation" of stressful situations is also mediated in part by low NO. A shift in the basal level of NO will shift the "desperation" setpoint to a more desperate level where people will do more desperate things.
I think this is part of what is making current society meaner and less tolerant.
You know, I think there is a danger of blaming biology too much for some things. Humans are remarkably resiliant, flexible and adaptable creatures, which survive under the most amazing variety of circumstances -- and one of the main ways we manage that as collections of individuals is by changing the way we do things as a group. This strength has allowed our population to expand to where it is currently, and I would say the tendency is pretty strong. The downside is the extent to which culture shapes people by itself -- because we've strengthened our tendency toward culture to the point that we absorb it, as well as creating it, even when it is not exactly of the best possible function or even maladaptive. (See Jared Diamond's Collapse for some great examples of this.)
I think we've currently gotten into a sort of feedback loop where culture drives nasty politics and nasty interpersonal interactions, and then the prevalence of those strengthen the "acceptability" of those things culturally. About the best we could do is push back in various ways, but it's not like this kind of thing changes just overnight. And what kind of cultural trend is present at the moment which would dethrone Ann Coulter and Rush Limbaugh?
I suppose it's possible we are messing with our body chemistry in ways which affect temperament -- personally, I'm more worried about our environment being awash with artificial hormones and our diets with extraordinary amounts of sugar -- but we need good evidence for its effect. In the case of NO metabolism, if a difference does exist, I think there's a good argument for it being driven by culture, rather than the other way 'round. Could be feedback, I suppose...but how would you demonstrate this?
Chris' Wills, the one place where I would really disagree with you is 3). I think that pressure to conform has *always* been an issue, as has insulting or shunning those who don't. I actually see less of that now than I think was present in the 50s-80s. I would also sort of mildly disagree with 1) -- white-collar workers probably did go through an extended period where there was assumed to be a mutual loyalty between worker and company, but blue-collar workers were always commodities. And the lower down on the food chain you were -- factory workers, mineworkers, that sort of thing -- the less the company you worked for ever regarded you as anything but a resource to be maximally exploited. This is abundantly evident in the history of labor relations from the beginning of the Industrial Revolution right up to the 80s, at least.
But I wholeheartedly agree with 4), and I think it goes with the fact that our entire "news-media" build on encouraging us to be fearful. We're afraid of each other. We're afraid of becoming victims ourselves. There's no denying that there ARE a lot of scam artists and predators, so it is a risk, and it wouldn't be wise to tell people to ignore it entirely, but still -- just about everywhere plays it up, and that lends itself quite nicely to treating other people with suspicion and hostility from the start, just about, which hardly reminds us of any obligation toward humanity.
Of course, the idea that people are automatically people, even when very different from ourselves in appearance and attitude, IS a relatively modern idea anyway, as is the concept of social obligation to support everyone as opposed to just the "worthy". I would agree that we are regressing.
Back to college students again -- maybe being removed from the safety of their family and family structure exposes students to a certain enhanced degree of fear for the first time as well, especially in this social climate.
What I find fascinating, though, is the difference in murder rates between students and non-students. In general, it looks like students are safer. That probably has a lot to do with socioeconomic status. The kids of that age who aren't going to college or university are far more likely to be lower economic status, working low-paying, low-skilled jobs, and without even the excuse for medical and social support that exists on campuses -- so, more crime, more violence, more stress, and more killing.
[old-fogey mode]Aaah, you students these days. Don't know how easy you got it...[/old-fogey mode] ;-)
Luna,
I'll happily accept the correction on 1; I've never been a blue collar worker (apart from summer jobs) and I was defenitely a commodity then.
on 3 It may be that I've been lucky and non-conformance wasn't an issue when I was growing up, I wasn't ever very non-conformist but some of the most popular kids at school were. Though that may be because Edinburgh was generally relaxed as far as I knew it.
On the people is people idea; is it that new or did the west change and then change again? I am thinking of the Byzantium empire which was multi-racial and internally peaceful for a long time. Also, was ancient Roman society racist? I know that it is going back a fair while and I agree that fear of the other has always been around.
I guess that it is built into us and perhaps the byzantiums and romans had another definition of other.
I think it is culturally driven. My hypothesis of why people are in a low NO state is due to the loss of their normal commensal ammonia oxidizing bacteria, which oxidize the ammonia in sweat into NO and nitrite, and so set the basal NO level. Perturb it a little, and then the feedback drives it further.
I think the endocrine disruption effects observed are more likely to to NO physiology, than to xenobiotics affecting endocrine receptors. NO is what regulates steroid synthesis. Change the basal NO level and you change the basal steroid level and also the steroid level under every other condition. Physiology can't compensate because it is the compensatory pathways that are affected.
There is no threshold for changes in the basal NO level to affect pathways involving NO. Any change will have an effect because NO is already in the active range, that is NO is already acting as an autocrine and paracrine regulator. Any change in NO will change what ever NO is regulating.