MR. RAY SUAREZThanks for joining us. I'm Ray Suarez sitting in for Diane Rehm. Suicide is now the tenth leading cause of death in the U.S. Nearly 43,000 Americans took their own lives in 2014. New data analysis by the federal government shows a sharp rise in the suicide rate over the past 15 years. Joining me in the studio to talk about suicide and what can be done to reverse this alarming trend, Jane Pearson of the National Institute of Mental Health Suicide Research Consortium, Katherine Hempstead of the Robert Wood Johnson Foundation and Holly Wilcox of the Johns Hopkins University.

MR. RAY SUAREZAnd from NPR studio in New York, Dr. Christine Moutier of the American Foundation For Suicide Prevention. Jane Pearson, the research was released on Friday, digested over the weekend. What are some of the key findings?

MS. JANE PEARSONWell, this takes a look at how the trends have been moving over time from 1999 to 2014 and the creep up has been rather slow. It's not a large jump at all, but it's definitely going in the wrong direction. So it's a 24 percent increase, which sounds more alarming maybe than what the creep up is, but it's definitely going the wrong direction. So the folks at the National Centers For Health Statistics take a look at this from time to time, try to put it into numbers that we can kind of understand and look at patterns.

MS. JANE PEARSONSo some of the patterns examined are how do male and female rates differ, how do the methods differ, looking at certain age groups, some racial and ethnic groups and that's what the report was about.

SUAREZMen kill themselves at a much higher rate than women, right?

PEARSONYes, about four to one.

SUAREZAnd that -- did that change at all as the 15 years progressed?

PEARSONIt's generally about the same, but we saw these increases in women that we haven't seen before. And I think that's what's of interest here, what's happening with these women that we would not expect to have happened.

SUAREZAnd a peculiar number among the youngest people.

PEARSONRight. So for adolescents, 10 to 14, the numbers went from 50 to 150 so it sounds like a very large number, but it's concerning. It's going in the wrong direction. So it's very difficult to think about, you know, finding those girls most at risk to do something about it because the numbers are rather small. But on the other hand, if we start looking at this and saying what else do we know about what's happening in terms of attempts, ideation, all of those pieces should start making us think about what else we should be doing.

SUAREZYou count the methods people use to end their own lives. Have those changed? And why is it important that we keep track of that aspect of it?

PEARSONSo that's really important because many countries have made progress in reducing suicide by dealing with the methods that people use. So it's almost like traffic safety where you can reduce some of the environmental hazards for accidents. You can actually reduce suicide risk. And a lot of it is buying time between somebody thinking about suicide and having access to the means. In our country, we still have firearms as the leading method.

PEARSONAnd that shifted somewhat. We had changes with women increases somewhat in suffocation, but the predominant number overall is still firearm suicide. So that's something we shouldn't forget and something we still have to work on.

SUAREZIs it possible that actually a lot more people kill themselves in America, but because of taboo, because of family shame or shock, because of the willingness of local authorities to record different kinds of deaths in different ways, that these numbers are actually covered up, that intentional overdoses are recorded as accidental overdoses, that intentional self killing is recorded as accidental when you use things like automobiles or firearms?

PEARSONRight. The question comes up a lot and it's a good one because I think we all can think of circumstances where we think that may have happened. I think for -- we know for sure that we haven't over-counted suicides. We know there's always under-counts. But I think, over time, we kind of keep those in mind and I don't think there's a big shift. We know that there can be shifts depending on if a state changes its approach to counting suicide deaths or not, you know, whether a coroner or medical examiner would require a note versus take all the information and make their best assumption or say, there looks like there was some intent here.

PEARSONWe're gonna call this suicide. So that varies, but I think we're getting better at that and I think there's also less stigma. If you look at national surveys, people do feel suicide is preventable, that people who are suicidal should get help, can get help. So I think we're starting to see a shift in that. There's still a lot to do, but I think it's getting better.

SUAREZBut are you getting the kind of cooperation you need from local authorities who are in the front lines of recording these deaths and recording the cause of death?

PEARSONThat’s beginning to happen and it's happening from state to state and we'll probably talk about the national violent death reporting system where states do pull together many teams. This is something supported by the CDC, medical examiners, the state suicide prevention leader, healthcare systems. You start putting the information together and then you find out this data is actually being used for prevention purposes. And I think that shift has really helped us think through better ways of doing this, more consistent ways of doing it.

SUAREZDr. Christine Moutier, what do you think is behind this rise?

DR. CHRISTINE MOUTIERWell, as we've been talking about, suicide is a complex human behavior, but research does very clearly show which risk factors and which protective factors come into the mixture to either increase risk or decrease risk. So if you look at the time frame that we're talking about from 1999 to 2014, there are a number of factors that likely were at play. And if I could just list a couple of them, you think about things like the changes in our nation's economy during that period of time.

DR. CHRISTINE MOUTIERYou look at prescribing habits of opiates and the number of opiate deaths that occurred over that period of time and linking that to simple access to lethal means that's out there now in so many more households. You can also think about the middle to older age population and what we've known about their cohort effect with higher rates of suicide and other kinds of problems that have, unfortunately, been with that population from a much earlier time in their life cycle. So probably a number of factors have come together.

SUAREZWe'll be taking your comments, questions throughout the hour. Call us at 800-433-8850. That's 800-433-8850. Send us your email at drshow@wamu.org. And, of course, as always, join us on Facebook or Twitter. Katherine Hempstead, when we take apart the numbers and look at discrete populations inside that gross number, you know, the conversation about the death rates of middle aged Americans got kicked off, I would argue, last year by Angus Deaton and Anne Case with their research out of Princeton.

SUAREZYour neighbor, Princeton and Robert Wood Johnson.

MS. KATHERINE HEMPSTEADThat's right.

SUAREZThese numbers on suicide illuminate that even more. Tell us more about what's going on with middle aged Americans.

HEMPSTEADWell, I think it does relate to some of what Christine just was saying and we have used the violent death reporting system, which Jane referred to, which is this very rich surveillance data set that CDC funds a number of states to keep which has really detailed circumstance information that's coded in kind of a consistent way from state to state. That actually allows people to look at what are some of the circumstances that are important for different age groups and change over time.

HEMPSTEADAnd one of the things that we determine when we're looking at the rise in the rates of the middle aged was an increasing recording or mention of factors that had to do with some kind of economic distress, whether it was a job problem, whether it was like a personal finance issue, like a foreclosure, a bankruptcy, a legal problem that maybe had to do with some kind of economic setback. So, you know, definitely got the sense that the Great Recession and some of the associated, you know, kind of problems that affect, in particular, the middle aged had something to do with the rise in suicide for this group.

HEMPSTEADYou know, but that being said, suicide is a very complex behavior that always has, you know, more than one risk factor underlying it.

SUAREZIt feels kind of risky to me, even though the numbers line up in a very compelling way, to assign something like economic stress to, after all, a coroner's report, a death certificate doesn't say, Bob lost his house last year, Jane hasn't worked full-time in two years. How to extrapolate that from the raw gross data. What are the kinds of things that help you get to that conclusion when sometimes the raw reporting is kind of mute on these factors?

HEMPSTEADWell, I mean, definitely it should be viewed sort of in context where, you know, there are lots of things that make particular people vulnerable to, you know, feeling overwhelmed by things that might happen to them. And I think what we see sort of is this underlying risk and then sometimes exogenous events can happen that affect many, many people in the population at the same time. And for some, it will really create a problem for them that results in suicidal behavior.

HEMPSTEADSo there has been, you know, a number of studies around the world and other times that have looked at the impact of, you know, economic crises on suicide and so we do see those kinds of patterns. In terms of finding the evidence, there's a lot of different sources of information that we use. The medical examiner report contains interviews with next of kin that can often, you know, mention things that the decedent have been worried about. There are things that are found at the death scene.

HEMPSTEADThere are things in a police report. Sometimes there are things in the media. So from those kinds of sources of evidence, we put together information and the abstractors are trained to sort of code in the standardized way the presence or absences of these different kinds of factors and that's what makes the balance of reporting systems so unique and useful.

SUAREZWell, you're listening to "The Diane Rehm Show." I'm Ray Suarez in for Diane. Coming up, more of our conversation on the rising suicide rate in America.

SUAREZWelcome back to the program. I'm Ray Suarez, sitting in for Diane Rehm. Today we're talking about the rising rate of suicide in the United States. The rate dropped for 13 years, from 1986 to 1999, and has been on a steady increase for the 15 years thereafter. And Holly Wilcox, what could be more heartbreaking, more stunning than the rise in attempted suicide and suicide among the youngest Americans? Even though the numbers are very small, and the rise that looks enormous is from a small base, it must still be concerning.

MS. HOLLY WILCOXIt is concerning. As rates do fluctuate, what we would want to look at if that was a sustained increase over time. So right -- what's reported is 50 deaths in 1999 and 150 in 2014, and so we would want to go back and look and see if that is sustained. It's something we should definitely keep our eye on. And I'm actually hearing that earlier intervention is needed by, you know, schools and our health care providers that I work with at Hopkins. So there is a need to intervene earlier for sure.

SUAREZDo 10-year-olds, 11-year-olds have more access to the means for trying to end their own lives? I mean, when you hear something like that, that a 13-year-old tried to kill herself, tried to kill himself, it is a disturbing and shocking thing. And then you start to wonder, well, how.

WILCOXAnd the thought is that younger folks, younger children, early adolescents, may have -- not have access to lethal means, and they may not have the cognitive capability to carry out a lethal attempt. But folks that age still do manifest suicidal thoughts and behaviors, and it's something that we should not ignore just because they're young. These could be red flags, or they could be real warning signs for death.

SUAREZYou know, if -- a 45-year-old is kind of a free agent in a way that a 12-year-old is not. Might we have more success in both flagging and preventing suicide among the youngest Americans because we channel and control and oversee their lives in a very different way?

WILCOXI do think that interventions that focus, that are delivered early, that are focused on building skills and setting kids up on a positive trajectory, should impact multiple outcomes, not just suicide thoughts and behaviors and suicide death but also substance abuse and other related outcomes.

SUAREZBecause of course for all ages, and I'll want to hear from my other guests about this, prevention, warnings interventions are important at any age. Extracting a what-to-do is a tough thing after you get a report like this one, coming up with a programmatic response, Katherine Hempstead. There isn't a one-size-all-fits answer, just as there isn't a one-size-fits-all explanation for why people do it. So this massive medical system we have, a huge but composed of a million parts kind of industry, can we ever do anything all at once, together, coordinated?

HEMPSTEADWell, I think there are lots of things that we can do. That being said, suicide is very challenging to prevent, and, you know, different cases have different kinds of risk factors. But many, many suicides have at their risk some kind of mental health or substance about problem. And these are things that are often really amenable to lots of improvement with medical treatment and access to health care.

HEMPSTEADAnd one of the things that I think is really salient in talking about the trend that we've seen is during the Great Recession, many, many people lost their health insurance, and we actually an uninsurance rate during that period that was almost twice as high as it is today. And now we've seen this really unprecedented increase in insurance. Close to 20 million have gained health insurance. And I think that that provides a real opportunity for some access to treatment for lots and lots of people because getting treatment for mental health or substance abuse disorders is really an important component of the advantages of having health insurance.

HEMPSTEADSo I think that that's one sort of glimmer of hope or something that might be a part of a solution that we can look forward to in the years to come.

SUAREZSo Dr. Moutier, we'll really want to see what those 2016 and 2017 numbers say, right?

MOUTIERYes, absolutely, and we hope that they will start trending down. But I will just highlight the fact that as a nation, we haven't made the level of investment on a federal funding level for research and prevention programs that has been made for many of the other top 10 leading causes of death in our nation. And we firmly believe that a similar investment and that kind of public health approach, where you teach the entire population about how to take better care, for example, of their heart health and other kinds of universal education strategies that have been employed for other health issues.

MOUTIERWe've seen that work alongside other kinds of more targeted strategies, training health care providers about how to detect mental health deterioration. And even outside the health care system, you can do the same thing, for example with teachers in even K-through-12 settings, since we're talking about younger children, as well. So there are a number of things we know do work and can work, but we have not yet scaled them up to the level that we'll see that kind of change in bending the curve of this, of our nation's suicide rate. But we believe that can happen, but we have to mount that kind of coordinated, large scale effort.

PEARSONI think it's important to know that we're trying to get those pieces in place in health care to make health care safer, and the joint commission issued in February a new sentinel event that says health care providers should be screening. There are things you can do. There's been a couple demonstration programs, and right now the NIMH has actually asked for applications to look at what improves health care, what makes it a safer system for suicide.

PEARSONAnd that also means not just during -- somebody being in the health facility. It's really thinking about what happens after they leave. We know that transition times are really high-risk periods. So the joint commission has recognized this, they've talked about this. Health care systems are on alert, and we're really hoping those improvements, plus what we could do in schools and communities, should really help.

SUAREZI want to remind you we'll start taking your calls momentarily at 800-433-8850. Of course the window is always open in social media, on Facebook and Twitter. And we've got an email from Mike. At what point should I take my minor thoughts about suicide seriously? I'm sure at some all people in America have thoughts about suicide, but when should we show concern about our thoughts? Great question.

MOUTIERI'll take that one. This is Christine Moutier. I think as a culture in our society, we are -- we're learning, and it's getting better, but historically we haven't taken our mental health terribly seriously, and we've attributed changes in mental health to the external events in our lives, and that's -- they do play a role, job loss and divorce and other kinds of stressors absolutely play a role with mental health and with suicide risk.

MOUTIERBut there's that layer of mental health and changes, and it's very real, it's physiological, and there are ways to address it. And so I would say that it's actually not every individual who has suicidal thoughts. It -- they're not uncommon, but many people who have those thoughts, once they start becoming more serious, frequent or turn into planning, while other risk factors might be coming into their life, you know, the thing is it's so low risk to go and talk to somebody about it and just process it out and kind of figure out what's driving them, what can be done about it.

WILCOXI would also like to add I think we're learning more and more about effective treatments. So in addition to, you know, improving the environment and making the environment safer, sort of that public health approach and the health care system, within that we've got people really working on some innovative things. People who are thinking very seriously about suicide have very distorted thinking, very hopeless, very constricted. If you have ideation that's not there all the time, you actually have a better chance of remediating that, of changing that, and we've -- there are a lot of psychotherapies that are very effective for this.

WILCOXAnd people are exploring other things like gaming to improve your thoughts, to help you not focus on the ideation.

SUAREZThe number is 800-433-8850. We'll go first to Manassas, Virginia, where Glen is calling. Glen, welcome to the program.

GLENThank you for taking my call. Quick question, and I'll take the answer off the air. Of the suicides and this rate -- period of increased suicides, how many of those were actually under the care of a mental health professional, and how many of them are actually receiving some kind of medication to help them?

WILCOXWell, I could answer that a little bit. From what we can tell from the Violent Death Reporting System, the share of decedents who had received mental health treatment is -- at some point at least is not low. It's something like 25 percent. But the details about medication we don't always have, and we don't always know, you know, exactly when that treatment might have ended, and, you know, and it varies a lot for different population groups.

WILCOXWe certainly think that in groups that don't necessarily have access to health care, have health insurance and maybe less educated groups, we see much lower reporting of having a mental health treatment history, which probably reflects more lack of access to care and sort of care-seeking behavior rather than necessarily a lower prevalence of a mental health problem. So there are definitely some times that we can see differences that probably, you know, have to do with access more than other things.

WILCOXBut I think a real step forward would be if we could even integrate that death certificate data with, you know, prior medical history and also be able to look at fatal and non-fatal suicidal behavior and look at what role mental health treatment is playing.

SUAREZJohn from Cleveland Heights, Ohio, follows up on that question. Almost 10 percent of the U.S. population now takes selective serotonin reuptake inhibitor antidepressants, called SSRIs, one of the most lucrative products ever developed by the pharmaceutical industry. Eli Lilly's own studies indicating that Prozac carries an increased risk of suicide even before its introduction in 1988, and multiple studies since have found that all the other SSRIs carry that same risk, as well.

SUAREZYet public radio and the rest of the mainstream media shun that fact like its' radioactive, well we didn't just now. Could any of your guests please explain why? Is John onto something?

PEARSONI can speak to it a little bit. We had a request for research on this topic, and the challenge here is that people who are depressed, who have suicide ideation, before they come into the door, you know, might already have the ideation. So trying to figure out what's an incident, what's a new incident of suicide that comes with the medication is a big challenge to understand. The FDA is requiring pharmaceutical companies to track this, and that's why you hear on all these commercials the risk of suicide with anything that affects your CNS, your central nervous system.

PEARSONSo you know, we -- we're hopeful looking at those trends early on when SSRIs first came out because more people were being treated for depression because the side effect profile is less, and primary care doctors could do this. But we've also started to try to figure out what's the risk-benefit from side effects versus the benefit of the medications themselves. So this is where we found that young people really didn't benefit as much from them and had more of these, you know, risky side effects.

SUAREZWhen you're on a drug like this, when it's been prescribed for one condition or another, do you get longitudinal follow-up, so at three months, six months, 12 months, 18 months, somebody's checking whether what they've given it to you for is being treated and whether you've got any of the side effects that are mentioned in that tiny, tiny type that comes along with the bottle of pills? Because if there's no follow-up, that's really where the problem comes, right?

PEARSONExactly, and we've learned that now in suicide prevention that the transition times, the follow-up times, how much medication is in the prescription you have, is really important. So those are the things we're saying we can do better at this. And I think -- go ahead, Christine.

SUAREZQuickly.

MOUTIERWell, I just wanted to add that getting good depression care is really important. It's an important aspect for suicide prevention and other mental health and substance abuse conditions, as well. But you're -- ray, you're exactly right that the problem is that if depression isn't followed along like diabetes or hypertension is, then you're not going to get the best outcome with your treatment no matter what it is, whether it's a psychotherapy or a medication.

MOUTIERAnd the other thing to note with the SSRI data and the black box warning is that this is -- it's a complicated situation. However, there have been no suicide deaths reported. So the increase was in ideation, for the most part, and the black box warning was really meant to do exactly what we're talking about, have closer follow-up after the time a new prescription is given to a patient or when the dose is changed.

MOUTIERBu the ultimate unintended consequence may have been that depression has not been diagnosed as much because -- or treated, and that goes for treatment with medications, and it was not, unfortunately, compensated for by other forms of treatment for depression. So there are some very concerning things that happened around that time that I think confused the American public about treating depression appropriately and may have also confused health care providers.

SUAREZI'm Ray Suarez. You're listening to "The Diane Rehm Show." If you'd like to join us, call 800-433-8850. Or send us an email at drshow@wamu.org. Or fine us on Facebook, or send us a tweet. Drugs are a big part of that story because that's a way that a lot of people are getting medical treatment for a wide range of conditions now. When you hear about the connection between chronic pain, long-term chronic pain and opioid use having a contributing factor to the rising death rate among middle-age Americans but also the suicide rate, how do we understand this? Help us unpack what's in there. People have always done physical work, suffered from chronic pain. Is -- are we treating people in a more hands-off, more bottle-connected way and considering them having health care?

HEMPSTEADWell, I mean, I think with regard to the opioids, we really flooded our system with a huge increase in supply of these, you know, very, very strong medications right around the time that we started to see the suicide rate go up. And, you know, now we're starting to really talk about changing our prescribing patterns, which is great, but in a certain way it's a little too late because a lot of the supply now is actually illicit and, you know, manufactured in other places and just being sold like heroin and other street drugs. So we still have this very large addiction problem.

HEMPSTEADAnd I think we saw with -- you know, with the study by Angus Deaton and Anne Case that addiction and drug use had a lot to do with this rise in mortality, you know, both overdose and secondary complications of substance us, and then also I'm sure that part of the rise in suicide that we see has a substance abuse component to it, too.

SUAREZA lot of these people begin with properly prescribed drugs and end up on illegal drugs, right?

HEMPSTEADA lot of them do and, you know, some of them don't. You know, I mean, right now that's a major part of our illicit drugs supply. So people are accessing them in all different ways.

SUAREZComing up, more of your calls and questions. Please stay tuned.

SUAREZWelcome back. I'm Ray Suarez, sitting in for Diane Rehm. We're talking about the rising rate of suicide in the United States. Jane Pearson, Dr. Christine Moutier, Katherine Hempstead, Holly Wilcox are all with me this hour. They can talk in an expert way about various parts of this enormous and very complex public health challenge. The number's 800-433-8850. Let's go to Sarasota, Florida where Anna is standing by. Hi Anna.

ANNAGood morning. Thank you for taking my call.

SUAREZAnd your question.

ANNAI'm so happy that we are having this discussion on a national platform and that you have so many experts at this table. I have a 12-year-old son who transitioned in middle school this year and it was very difficult for him. And at one point, he finally broke down and said, I just feel like I want to die. I just feel like I want to kill myself. And we found an amazing therapist who then referred us on to an amazing psychiatrist who we now see every three months because he is on Prozac and he's also on Ritalin for focus.

ANNABecause she felt like that was something he needed as well. And we have really enjoyed the relationship that we have, and I think it's an amazing outlet for him to be able to discuss his feelings. And what I'm wanting to know is how can we keep lessening the stigma of this, especially with our young children, so that they know that when they have these problems, they can come and talk to us and as parents, we can be there to support them so that they don't have to make that choice of ending their lives.

SUAREZAnna, stay with us. Holly Wilcox.

WILCOXThank you so much for your call. And we often hear such negative, the negative aspects of suicide and this issue, I know, is difficult to talk about, but it's also nice to hear that there are successes and good things going on. One thing that we're doing now at Johns Hopkins is we've just finished up a project that was in 68 schools in the United States. And we are working with high school teachers and high school students in delivering an intervention in health education class.

WILCOXSo it's imbedded right into health education class. Everyone receives this intervention in the school, as long as they're registered in health education class. We train the teachers on how to deliver a depression education module curriculum for the students. And that module covers how to distinguish clinical depression from just feeling sad. And it also addresses stigma. So this is one program that we've tested. We're testing now with a randomized trial. And really trying to establish that this works and it appears like it does increase depression literacy in students.

WILCOXAnd mental health literacy, so that they learn from it. And that -- in some populations, it also does impact mental health stigma.

SUAREZThis is a good moment to remind people they can reach out to professionals at the National Suicide Prevention Lifeline. The number is 800-273-TALK. That's 800-273-8255. Anna, hearing your own child tell you that must be just the kind of thing that buckles your knees. And you talked about lessening the stigma, but when you first heard that from your own child, did you also worry about who should know, who must know, and who can't know that he just said that to you?

ANNAAbsolutely, and you know, in our own family, I've felt like this was something we kind of needed to keep to ourselves and even got some slight pushback from my husband as saying, you know, this is puberty and a hard time and we all go through it. And we kind of just need to pull ourselves up by our bootstraps and get through it. But I recognize that that's not something I wanted to look back on if heaven forbid something happens. We do not have guns in our home. We do not have prescription medication. So I knew that we had those safeguards.

ANNABut I knew that I needed that outside help and so I had to pushback, even from my own spouse to say, listen, I don't think we can handle this by ourselves. And I want to get someone who does this every day and sees this is just, you know, the teenage angst. Or if this is, you know, clinical depression. Which it was, which it is. And we, you know, need help, because my son was saying, I feel so much pressure in school and I feel so much pressure to be perfect.

ANNAAnd I look now at these headlines about these talented students across the country that are -- I'm wondering if they're taking their lives because of this pressure to be perfect and at school. And I wanted to stop this in middle school, before high school, before college.

SUAREZCalibrating the response must be the biggest challenge, because you don't want to under react. And believe me, when I heard your husband's words there, Anna, I thought, well, I know where that kind of answer comes from. being the sole man on this morning's program. But I also -- we also don't want to over respond and bombard a kid and convince him that he's broken, plots somewhere way outside the normal continuum of life and convince him at a very early age that he's got this terrible, terrible and unsolvable problem.

SUAREZDr. Moutier, how do you quickly, too, come in with a response that makes for an individual kid? This is a problem that we're trying to answer in a mass population, but also come up with solutions that are as individual as a thumb print.

MOUTIERAbsolutely. And I really commend you. And this is a really important topic. I don't think it has to be either/or. I think there's a way to talk to your child or frankly anyone in your life, and this is part of the public health approach, actually, that can reduce stigma, to say we are all part of the human race. In the human condition, there are many, many challenges that each and every one of us will face. Sometimes, that delves into the mental health arena and in fact, it's not uncommon. So, the more we can kind of, in a way, it's sort of ironic in a way.

MOUTIERIt's normalizing that these are common health conditions, that there is simply no shame in getting them addressed and the other thing is, in real time, you know, to talk to a mentor, teacher, therapist or pastor, to just start processing what it is. What are those feelings? I don't think that has to give the message to a child that there's something horribly wrong with them that makes them different. I think it actually can be a sign of strength and the adults in a child's life can actually tell them that. And role model that.

SUAREZFrom the virtual email bag, I'm Jessica, age 20, from Greenville, Indiana. And I've recently considered suicide on a number of occasions. I'm really surprised how well I fit the profile. I don't see an economic future for myself and the main place I break down is at work. From Susan in Davie, Florida. My dad and my stepfather both killed themselves many years after being divorced from my mom. They were both self-medicating alcoholics. Both super-intelligent men who never quite made the lives they wanted. This continues to devastate my family.

SUAREZAnd from Tamarac, Florida, Tony writes, is there any connection between religious beliefs and suicide? More precisely, is religious affiliation an inhibitor of suicide? Do we know?

HEMPSTEADThe research is very difficult to do there, because part of being in a religious community is sometimes the interactions in a community. For some people, it's really your inner spiritual faith, so to just get an affiliation on a survey or something and try to make sense out of it is a challenge. But I think the older research would say the religions that have more prohibitions against suicide and the whole moral issue there could look protective at times. But given our conversation today, you can see where that would be not a good thing to get help.

HEMPSTEADSo unless you could -- we actually work with the faith community through the National Alliance for Suicide Prevention. Where there are some real common things across all faiths where we do want people to go get help. And we do want faith leaders to understand when it's time to make the referral. And...

SUAREZWell, we do know from the stats that Latinos and blacks, black women in particular, who stereotypically are -- but also, I think, in the data, more church affiliated than other groups of Americans. Also have lower rates of suicide. Is it too much of a leap or too early of a leap to enmesh those two sets of statistics?

HEMPSTEADI think as researchers started to look at that, you, if you look at college -- African-American college students who might be grounded in some of those, they're not always protected from thoughts of suicide. So, I think that data was a while ago. I think it is time to look at this again. We do need to figure out where our strengths are, build on those. And I would also mention, just to add to what Holly was saying about the high school students, we're learning a lot about what we can do, even in elementary school age kids. Not specifically suicide curricula, but building their strengths, their skills and parenting skills.

HEMPSTEADSo you can actually have conversations. I think Christine's point that being able to talk to your kid about this, and even saying to your child, I'm so glad you told me about this, because now we can do something about this is great.

PEARSONAnd I would just add that, you know, one of the things about religion is the connectedness with other people and it just, you know, reminded me of one of the points I thought we would make today is there is a big geographic pattern in suicide and we tend to find higher suicide rates in places that are less densely populated and some of that has to do with the prevalence of gun ownership. But I think another aspect is isolation and people not necessarily having someone to notice that they're not doing well. Or have someone to talk about. So that affects peoples' access to getting help.

SUAREZHolly Wilcox, one of the first places some people, some families realize there's a problem is in the emergency room when suicide has been attempted. What is done at that point of treatment? The attempt has been unsuccessful, but now you've got someone you know is a danger to themselves. You can't just say, well, here, head home and don't do that anymore. What kind of services are delivered right there in the moment that leads, eventually, to a discharge with some confidence, that this isn't going to just repeat itself?

WILCOXThere has been a lot more work taking place in emergency departments because suicide is a major patient safety area that health care practices are focusing on. And there has been a push by the Joint Commission for emergency departments to screen patients who come in with behavioral health complaints. Or all patients for suicide risk. And then to be prepared to manage that patient there. And that could involve some level of follow up and coordination of care after they leave that ideal -- in ideal circumstances, they will get that after they leave the emergency department.

WILCOXBut there have been lots of health care practices now that have been using screening to identify some people who come in with suicidal thoughts and attempts.

SUAREZI'm Ray Suarez. You're listening to The Diane Rehm Show. Let's go out to Detroit, Michigan where Doug is standing by. Hi, Doug. Doug, are you there?

DOUGHey, hey guys. How are you? I just wanted to make the point that if you go to a professional and admit that you have a suicidal tendency, you're immediately taking away the option of suicide, which prevents people from even wanting to pursue help.

SUAREZWell, if I understand you, you're immediately, what, admitted? What are you saying, Doug? That when you admit you have a problem, you're treated in such a way that it creates a disincentive to admit you've got a problem?

DOUGExactly. If you go to a medical professional, the first question they ask you, are you a danger to yourself or others? And if you say yes, something's going to happen, and that's going to limit your options if you should decide that you want to commit suicide. So, that by itself is a disincentive from seeking help.

SUAREZThat's an interesting idea. Let me hear what my panelists have to say about that.

PEARSONWell, I would say we're trying to figure out ways to work with patients, not have it as this struggle or fight for somebody's autonomy. It's really wanting to talk to somebody and hear why they're suicidal. And what's happening and what led you to this so we can do something about it? And more skilled healthcare professionals are learning these things. There's a number of states that are requiring healthcare providers, now, to get training in this, so we are improving care. Unfortunately, I'm sure there are a lot of bad examples out there of where this has not gone well.

PEARSONIncluding emergency departments, but we're making progress there. Besides the screening, I think we are teaching people how to do motivational interviewing, how to get people motivated to get the help that they need. So, I'm sure there will still be these bad cases, but I think we're trying to change that whole conversation.

SUAREZI want to remind listeners that the National Suicide Prevention Hotline is open 24 hours a day, every day of the week, to take your calls at 800-273-8255. That's 800-273-TALK. And if you visit the Diane Rehm Show website, there's more resources listed there and links for people who want more information, either for themselves or someone they love. Can we, out of this data, we know what's wrong, we know what's happening, Dr. Moutier, can we extrapolate some to-do's for the healthcare industry?

MOUTIERAbsolutely. On a high level, system level basis, there are many things that can be done. And there are efforts underway to sort of empower and equip healthcare systems to be able to detect those people who are at risk for suicide, to give them the right kind of compassionate and aligning with them. To the last caller's point, that's a very unfortunate kind of perception that again, may have existed. But there are new treatments that have been developed that specifically align doctor and patient together as they work through those things.

MOUTIERSo, on a system level, there are many things that can be done. And there are efforts in various states that Jane mentioned. It's very exciting. That's something that can absolutely be studied further, but also scaled up in the meanwhile, because some of it is just common sense. And not letting people who are at high risk fall through the cracks in the healthcare system. And then, when it comes to individual healthcare practitioners, there are many kinds of educational trainings that they can get, depending on what kind of practice that they're in to again allow them to detect who is at risk that they're treating.

MOUTIERAnd when they are and how to behave in their treatment with them. So, those kinds of treatments have been developed and studied and some of them are fairly recent developments. So that I would say to those healthcare providers out there, if you don't know what this is all about, you don't need to feel like you somehow missed something in your training. Some of it is actually new. And I think the idea is to be open minded to it and embrace it. So, number of exciting opportunities. On a public health level, we actually also believe that everyone, every citizen, has a role to play when it comes to preventing suicide.

SUAREZQuick final thoughts. Katherine Hempstead.

HEMPSTEADYeah, I think that those are great points. And I think with mental health treatment, there is really still quite a supply problem and there are many people, even people with insurance that are waiting long periods of time for appointments and, you know, just not getting the care that they need. So, I think that we need to really look to better using telecommunications and other kinds of methods to really increase the supply of treatment.

SUAREZThat's Katherine Hempstead, Senior Advisor for Healthcare at the Robert Wood Johnson Foundation and a long time suicide researcher. She joined me along with Jane Pearson, Chair of the National Institute of Mental Health's Suicide Research Consortium. Holly Wilcox, Associate Professor at Johns Hopkins University School of Medicine and the School of Public Health. And expert in child and adolescent suicide prevention. And from New York, Christine Moutier was with us, Chief Medical Officer of the American Foundation for Suicide Prevention.

SUAREZThank you all for joining us. I'm Ray Suarez in for Diane Rehm.