The immigrant from India believed her husband when he said that if she wasn’t gone by the time he got to their Georgia home in 10 minutes, he would kill her.

She said her husband and his family, who are also immigrants, abused her throughout their marriage, beating her with a belt, pouring hot water on her, cutting her, and pushing her head through a wall.

“Several times I tried to escape, but they found me and brought me back home,” said the woman, who is in the country illegally and spoke on the condition of anonymity because she is afraid being identified would harm her chances of gaining legal status.

With no time to run after her husband’s call in July 2020, she dialed 911, even though she knew she could be deported. The police arrived to find the husband threatening her with a knife in front of their young children, she recalled. He was arrested but not prosecuted, she said.

The woman and her children sought services from the Tahirih Justice Center, a national nonprofit organization that serves immigrant survivors of gender-based violence. She is still winding through the immigration process five years later.

Besides immigrants’ increased vulnerability to sexual violence, they face a host of mental health and physical challenges, researchers say. They have high rates of post-traumatic stress disorder, depression, suicide, and anxiety, according .

“Personally, I know anxiety related to the current political climate is precipitating expensive emergency room visits and negatively impacting people’s ability to get to work and make a living,” said Nicole E. Warren, a nurse midwife and an associate professor at the Johns Hopkins School of Nursing in Baltimore.

Immigrants without legal status also face increased rates of chronic conditions and higher death rates from preventable diseases due to their limited access to health care and their fear of seeking it, advocates say.

“One of our clients was so afraid to leave her home that she avoided seeking medical care during her pregnancy, out of fear of interacting with ICE,” said Miriam Camero, director of client advocacy, social services, at Tahirih.

Food banks have reported that many immigrants in need of food assistance have stopped coming, for fear of deportation.

It has always been difficult for people without legal immigration status to get help when they need it. The Trump administration’s crackdown on people in the country illegally has intensified the pressure. The situation has also hampered the advocates and attorneys who defend their rights.

“We’re working extra hours to do all the work,” said Vanessa Wilkins, executive director of Tahirih’s office in Atlanta. “The safety planning and added protection that clients might need, including documents just to make sure they are safe, can definitely make you feel overwhelmed.”

U Visas

For domestic abuse survivors without legal status, like the woman from India, going to the authorities seems more fraught amid the immigration crackdown, said Maricarmen Garza, chief counsel of the American Bar Association Commission on Domestic & Sexual Violence.

“There are just no guarantees,” Garza said, “especially with how law enforcement is intertwined in enforcing immigration law.”

In more than half of states, U.S. Immigration and Customs Enforcement agents can collaborate by formal written agreements with state and local law enforcement agencies to identify and remove people in the country illegally. Advocates say this can interfere with victims’ efforts to get a certificate to file for a “U visa,” which would allow them to live and work in the U.S. with the possibility of lawful permanent residency.

The battered woman from India recalls police telling her that if she did not press charges, she could get a certificate for a U visa. She agreed to their suggestion but recalls the anxiety of filing about five abuse reports over two years to get the certificate. “I got panic attacks just writing them down, because it meant I was reliving the situations again,” she said.

When asked for comment about the difficulties immigrant domestic violence victims face, White House spokesperson Abigail Jackson touted President Donald Trump’s efforts to crack down on illegal immigration. “The president’s successful effort to deport criminal illegal aliens is making all victims safer and ensuring they will never again be harmed by dangerous criminal illegal aliens,” Jackson said in a statement. She said “allegations without evidence” that immigrants have been told to drop charges “should not be taken seriously.”

Immigrant women without legal status can be particularly vulnerable to abuse and exploitation because of language barriers, as well as cultural and social isolation,

According to , lifetime rates of abuse by intimate partners range up to 93% in some immigrant groups, compared with about 41% of U.S.-born women experiencing such abuse in their lifetime.

As the Trump administration reshapes the country’s immigration system, survivors of violence who entered the country illegally have a tough time proving their abuse and trauma to get relief, advocates say.

A refugee health and asylum program at Johns Hopkins in Baltimore provides immigrant victims of abuse with free forensic evaluations to support their claims for humanitarian relief, including applications for U visas.

Warren, the program’s associate director for women’s health, said that in the past, a written affidavit of the clinic’s findings was enough to corroborate an applicant’s legal accounts of past trauma.

“Now, we are getting requests for our in-person testimony,” Warren said.

Application Backlogs

The woman from India applied for a visa after she received a certificate from law enforcement allowing her to do so in 2023. Hers is one of nearly 11.6 million pending visa applications, — the highest volume of cases ever recorded by U.S. Citizenship and Immigration Services. The number of pending U visa applications is 415,000, according to the agency.

Only about 10,000 U visas are issued per year, and it can take more than seven years to process applications, Garza said.

Adding to the pressure, the Trump administration has reduced the availability of Section 8 housing, which helps low-income individuals and others pay their rent. , people without legal authorization to be in the United States are not eligible to receive rental help over U.S. citizens.

“If Tahirih wasn’t behind me, I could be homeless,” said the woman, who said she can afford only half her rent.

Victims’ advocates say they are working harder than ever to support their clients but are stretched thin as they face federal funding cuts and increased demand.

The Tahirih center reported a 200% increase in call volume in the four months after Trump took office, compared with the same period last year.

“At the end of the day there are a lot of emails and a lot of people we aren’t able to reach as quickly as in the past,” said Casey Carter Swegman, the center’s director of public policy.

To reach immigrant survivors of abuse who are afraid to come forward, advocates are “getting back to basics,” said Joanna Otero-Cruz, executive director and president of the Philadelphia group Women Against Abuse.

“We’re doing grassroots outreach to hairdressers and other small-business owners,” she said. “They’re the eyes and ears for us.”

In Riverhead, New York, a 38-year-old woman who emigrated from El Salvador said she has twice been the victim of domestic abuse but was too scared to report it to police.

She said the second assault was by a man for whom she cooked and cleaned in his home. The woman, who spoke on the condition of anonymity because of her sense of shame and her fears of deportation, said he raped her, took pictures of her naked, and threatened to put them on social media if she tried to go to the police. He then stalked her, she said.

Noemi Sanchez, Long Island regional coordinator for the Rural & Migrant Ministry, a nonprofit that supports farm workers, is working closely with the woman to elevate her self-esteem and help her understand that “no woman deserves to have a man mistreat them.”

Meanwhile, the survivor from India received a temporary work permit in 2024 and is employed as a certified nursing assistant, which “helps me survive,” she said.

“I have really come a long way,” she added. “It wasn’t easy. I had great support behind me. They didn’t let me down.”

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If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

Elliott Hinkle experienced depression and suicidal thoughts even before entering the foster care system in Casper, Wyoming, at age 15.

At the time, Hinkle, who is transgender, struggled with their sexual identity and gender issues, and their difficulties continued in foster care. They felt like they had no one to confide in — not their foster parents, not church leaders, not their caseworker.

“To my knowledge, I don’t remember ever taking a suicide screening,” Hinkle said. “No one ever said: ‘Are you having thoughts of taking your life? Do you feel hopeless?’”

With their psychological and behavioral health needs left unaddressed, Hinkle’s depression and suicidal thoughts worsened.

“Do I stay in the closet and feel terrible and want to end my life?” Hinkle said. “Or do I come out and lose all my supports, which also feels dangerous?”

Children in foster care are significantly more likely to have mental health issues, researchers say. They attempt or complete suicide at rates three to four times that of youths in the general population, according to .

LGBTQ+ people in foster care, like Hinkle, are at an even of having suicidal thoughts.

Yet despite the concentration of young people at risk of serious mental illness and suicide, proactive efforts to screen foster children and get them the treatment they need have been widely absent from the system. And now, efforts underway to provide widespread screening, diagnosis, and treatment are threatened by sweeping funding cuts the Trump administration is using to reshape health care programs nationwide.

In June, federal officials announced they would serving LGBTQ+ youths as part of those cuts.

Children in foster care use a disproportionate amount of Medicaid-funded mental health services. Meanwhile, President Donald Trump’s massive budget package, passed this month by Congress, contains substantial that are projected to drastically reduce services in many states.

“I think anybody who cares about kids’ well-being and mental health is concerned about the possibility of reduced Medicaid funding,” said Cynthia Ewell Foster, a child psychologist and clinical associate professor in the University of Michigan psychiatry department. “The most vulnerable children, including those in foster care, are already having trouble getting the services they need.”

A lack of federal standards and other system-level issues create barriers to psychological and behavioral care in the child welfare system, said Colleen Katz, a professor at Hunter College’s Silberman School of Social Work in New York.

“When you’re talking about anyone getting screened for suicide ideation upon entrance into the system, it’s inconsistent at best,” she said.

Katz said all children entering foster care should have a brief, standardized suicide screening embedded into their initial medical assessment. And more screenings need to be conducted throughout a foster care stay, she said, because youths getting ready to transition out of the system are also vulnerable. 

Hinkle, now 31, said the summer before they aged out of the system was “one of the darkest periods, because I was coming to terms with the church not wanting me to be gay and I was about to lose stable housing and whatever foster care support there was.”

Katz studied transition-age youths in foster care in California, which has the highest numbers of placements in foster care nationwide. According to , 42% of study participants had thoughts of taking their life and 24% had attempted suicide, and she expects findings would be similar in other states.

Katz also and found many that already exist could work and be easily administered by trained child welfare workers or alternative frontline service providers, or embedded in existing mental health services.

Still, the quality of services varies by state and locality and can hinder attempts to curb suicides.

Julie Collins, vice president of practice excellence at the Child Welfare League of America, which advocates for improvements to the child welfare system, said the gap in suicide prevention in foster care mirrors the overall nationwide void of behavioral health services for children and adolescents. “The preparation of people coming into the field isn’t what it needs to be,” Collins said of the lack of training for caseworkers.

Ewell Foster is trying to change that.

She worked with the state of Michigan to redefine and update the competencies required to earn an undergraduate certificate in child welfare in the state. Eighteen colleges and universities that offer certificate programs in child welfare in Michigan now teach about suicide prevention.

“It’s something the workforce has asked for,” Ewell Foster said. “They need real clear guidance on what to do when they are worried about someone.”

So far, Ewell Foster’s effort to change the wider system has not run into any roadblocks. Her work with Michigan’s child welfare agency is still being funded under a grant administered by the Substance Abuse and Mental Health Services Administration.

Agency spokesperson Danielle Bennett said such grants will continue for up to three years.

However, the future of the federal agency has been in question for months. The Trump administration has laid off hundreds of its employees and has proposed folding its functions into another agency.

Some states have made changes to address the foster care gaps on their own, but often it has taken legal action to spark changes in suicide prevention efforts.

In Kansas, officials made several changes after the state settled the McIntyre v. Howard class action lawsuit in 2021 on behalf of foster children who the suit alleged were subjected to inadequate access to mental health resources and moved from home to home frequently.

The state increased salaries for social workers in the child welfare system and reduced their caseloads, among other things.

Other states, including Texas, have implemented similar changes after facing lawsuits.

Still, experts caution that the changes taking place in foster care systems are not enough to steer outcomes.

Lily Brown, an assistant professor of psychology and director of the Center for the Treatment and Study of Anxiety at the University of Pennsylvania Perelman School of Medicine, said moving the needle in suicide prevention will require for children in state care.

Brown recently sought a grant to fund and implement free, universal suicide risk screening in foster care throughout Pennsylvania. She had several counties agree to the project, but not enough to support her application — the study wouldn’t have had enough participants to work statistically, she said.

Without such studies, foster care systems nationwide can’t meet the needs of children, she said.

April Miller, 27, entered the system in Minnesota at age 3. As a Native American, she is part of a group that is overrepresented in foster care.

“The child welfare system as a whole neglected me,” said Miller, who said she endured several traumatic events in her early life, including witnessing a murder.

“I did a lot of self-harm and had thoughts of suicide but didn’t have access to means, which is why I am still alive,” she said.

Today, Miller is a social worker and suicide prevention coordinator in Bemidji, Minnesota.

Similarly, Hinkle’s experience in the system made them driven to change the trajectory of other young people.

Hinkle provides training, consultation, and policy development services at Unicorn Solutions in Oregon in support of youths and young adults affected by systems such as child welfare, with a particular focus on the LGBTQ+ community.

They said they are committed to making sure that sexual identity and gender topics are not avoided in the system.

“I think every young person should feel loved and cared for,” Hinkle said.

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“It put a smile on my face to see him so happy,” Schachter said.

Alex would have turned 21 that day, six years after he and 16 other children and staff at Marjory Stoneman Douglas High School in Parkland, Florida, were shot and killed by a former student in 2018. In the years before the shooting, that former student had displayed concerning behavior that to 911 and at least two tips to the FBI.

“Alex should still be here today. It’s not fair,” Schachter said.

After two weeks of grieving Alex’s death, Schachter, propelled by anger and pain, began advocating for school safety. In part, he wanted to ensure his three other children would never be harmed in the same way. He joined the newly formed Marjory Stoneman Douglas High School Public Safety Commission to improve the safety and security of Florida’s students. And he launched a , which advocates for school safety.

Doing that work, he learned about threat assessment teams, groups of law enforcement and school officials who try to identify potentially dangerous or distressed kids, intervene, and prevent the next school shooting. Florida is one of that require schools to have threat assessment and intervention teams; a national survey estimates have a team assigned to the task.

The teams, whose mission and operational strategies often are based on research from the FBI and the Secret Service’s National Threat Assessment Center, or NTAC, have become more common as the number of school shootings has increased. Despite their prevalence for almost 25 years, some of the teams have developed systemic problems that put them at risk of unfairly labeling and vilifying children.

States vary widely in their requirements of threat assessment teams and there isn’t a nationwide archetype. Few school districts and states collect data about the teams, little is known about their operations, and research on their effectiveness at thwarting mass shootings and other threats is limited. But a by the NTAC of 67 plots against K-12 schools found that people “contemplating violence often exhibit observable behaviors, and when community members report these behaviors, the next tragedy can be averted.”

“School shooters have a long thought process. They don’t just snap. They have concerning behavior over time. If we can identify them early, we can intervene,” said Karie Gibson, chief of the FBI’s Behavioral Analysis Unit.

Yet, Dewey Cornell, a forensic clinical psychologist who in 2001 developed one of the first sets of guidelines for school threat assessment teams, said there have been problems. In many cases, he said, threats have been deemed not serious “but parents and teachers are so alarmed that it is difficult to assuage their fears. The school community gets in an uproar and the school administrators feel pressured to expel the student.”

And in other cases, a school doesn’t do a threat assessment and assumes a student is dangerous when somebody else reports them as a threat, and they may take a zero tolerance approach and remove them from the school, said Cornell, the Virgil S. Ward professor of education at the University of Virginia.

A task force convened by the found little evidence that zero tolerance policies have improved school climate or school safety and said they may create negative mental health outcomes for students. The task force cited examples of students who were expelled for incidents or school rule violations as minor as having a knife in their lunch box for cutting an apple.

Marisa Randazzo, a research psychologist and the director of threat assessment for Georgetown University, said she has also seen “hyperreactions,” especially among school communities that have experienced a mass killing.

“It’s understandable. People who have been close to an event like this are on higher alert than other people,” said Randazzo, who previously worked for the Secret Service and co-founded Sigma Threat Management Associates.

Threat assessments are supposed to be a graduated process calibrated to the seriousness of a problem, since the majority of student threats are not credible and can be resolved through supportive interventions, from the Secret Service.

Stephanie Crawford-Goetz, a school psychologist and the director of mental health for student support services in the Douglas County School District in Colorado, where a at a charter school in 2019, said her district’s threat assessment process emphasizes a proactive, rehabilitative approach to managing potential threats, as the NTAC suggests.

Crawford-Goetz said her district interviews students before convening the team to assess whether a threat is a misguided expression of anger or frustration and if the student has a plan and means to carry out violence.

Students whose threats are deemed transient receive support, such as help with coping skills, and they may meet with a mental health provider.

If the threat is credible, a student may be temporarily removed from the classroom or school.

Randazzo said the vast majority of kids who make threats are suicidal or despondent: “The process is designed primarily to figure out if someone is in crisis and how we can help. It is not designed to be punitive.”

Crawford-Goetz tells parents about her district’s threat assessment team at the beginning of the school year. Some districts report keeping their teams a secret from parents, which is not how they were designed to operate, said Lina Alathari, chief of the NTAC. Her team encourages schools to educate the whole community about the threat assessment process.

Some advocacy groups contend that threat assessment teams have perpetuated inequities. There has also been widespread concern that children with disabilities can easily get swept into a threat assessment.

In a 2022 report, the National Disability Rights Network, a nonprofit based in Washington, D.C., said some threat assessment teams have become “,” going beyond assessing risk of serious, imminent harm to determining guilt and punishment.

Expanding their scope allows threat assessment teams to get around civil rights protections, the report says.

Cornell disputed the disability rights group’s conclusion. “This has not been corroborated by scientific studies and is speculative,” he said.

Some states, such as Florida, mandate that threat assessment teams determine whether a student’s disability played a role in their behavior and recommend they include special education teachers and other professionals in their evaluation.

In Texas, which has mandated threat assessment teams, a third of students subjected to threat assessments in the Dallas Independent School District receive special education services.

Yet, the district a special education staff representative on its threat assessment team, according to a March 2023 report by Texas Appleseed, a nonprofit public interest justice center.

Many school districts are developing their own models in the absence of national standards for threat assessments.

Florida revamped its threat assessment system in January 2024 to improve response times, provide consistent data collection, and build in more checks and balances and oversight, said Pinellas County Sheriff Bob Gualtieri, who is also chair of the Marjory Stoneman Douglas High School Public Safety Commission.

The new model requires the teams to work quickly and file uniform, electronic summary reports of threat assessment findings. Those results follow students throughout their school years.

The adjustments are intended to eliminate the risk of not knowing about a student’s past troubling behavior if they change schools, as occurred with the Parkland shooter and a student who shot and killed classmates at a high school near Winder, Georgia, in September, said Gualtieri.

“As parents, you never stop worrying about your kids,” Schachter said.

Virginia mandates that all public schools and higher education institutions, including colleges, have threat assessment teams. In Florida, where one of Schachter’s daughters attends college, threat assessment teams are mandated in all public schools, including charter schools.

“There’s more work to be done,” Schachter said.

Cheryl Platzman Weinstock’s reporting is supported by a grant from the National Institute for Health Care Management Foundation.

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If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

When Pooja Mehta’s younger brother, Raj, died by suicide at 19 in March 2020, she felt “blindsided.”

Raj’s last text message was to his college lab partner about how to divide homework questions.

“You don’t say you’re going to take questions 1 through 15 if you’re planning to be dead one hour later,” said Mehta, 29, a mental health and suicide prevention advocate in Arlington, Virginia. She had been trained in — a nationwide program that teaches how to identify, understand, and respond to signs of mental illness — yet she said her brother showed no signs of trouble.

Mehta said some people blamed her for Raj’s death because the two were living together during the covid-19 pandemic while Raj was attending classes online. Others said her training should have helped her recognize he was struggling.

But, Mehta said, “we act like we know everything there is to know about suicide prevention. We’ve done a really good job at developing solutions for a part of the problem, but we really don’t know enough.”

Raj’s death came in the midst of decades of unsuccessful attempts to tamp down suicide rates nationwide.

During the past two decades federal officials have launched three national suicide prevention strategies, including one announced in April.

The first strategy, announced in 2001, focused on addressing risk factors for suicide and leaned on a few common interventions.

The next strategy called for developing and implementing standardized protocols to identify and treat people at risk for suicide with follow-up care and the support needed to continue treatment.

The latest strategy builds on previous ones and includes a federal action plan calling for implementation of 200 measures over the next three years, including prioritizing populations disproportionately affected by suicide, such as Black youth and Native Americans and Alaska Natives.

Despite those evolving strategies, from 2001 through 2021 suicide rates , according to the Centers for Disease Control and Prevention. , the most recent numbers available, shows deaths by suicide grew an additional 3% over the previous year. CDC officials project the final number of suicides in 2022 will be higher.

In the past two decades, suicide rates in such as Alaska, Montana, North Dakota, and Wyoming those in urban areas, according to the CDC.

Despite those persistently disappointing numbers, mental health experts contend the national strategies aren’t the problem. Instead, they argue, the policies — for many reasons —simply aren’t being funded, adopted, and used. That slow uptake was compounded by the covid-19 pandemic, which had a broad, negative impact on mental health.

A chorus of national experts and government officials agree the strategies simply haven’t been embraced widely, but said even basic tracking of deaths by suicide isn’t universal.

Surveillance data is commonly used to drive health care quality improvement and has been helpful in addressing cancer and heart disease. Yet, it hasn’t been used in the study of behavioral health issues such as suicide, said Michael Schoenbaum, a senior adviser for mental health services, epidemiology, and economics at the National Institute of Mental Health.

“We think about treating behavioral health problems just differently than we think about physical health problems,” Schoenbaum said.

Without accurate statistics, researchers can’t figure out who dies most often by suicide, what prevention strategies are working, and where prevention money is needed most.

Many states and territories don’t allow medical records to be linked to death certificates, Schoenbaum said, but with a handful of other organizations to document this data for the first time in a public report and database due out by the end of the year.

Further hobbling the strategies is the fact that federal and local funding ebbs and flows and some suicide prevention efforts don’t work in some states and localities because of the challenging geography, said Jane Pearson, special adviser on suicide research to the NIMH director.

Wyoming, where a few hundred thousand residents are spread across sprawling, rugged landscape, consistently ranks among the states with the highest suicide rates.

State officials have worked for many years to address the state’s suicide problem, said Kim Deti, a spokesperson for the Wyoming Department of Health.

But deploying services, like mobile crisis units, a core element of the latest national strategy, is difficult in a big, sparsely populated state.

“The work is not stopping but some strategies that make sense in some geographic areas of the country may not make sense for a state with our characteristics,” she said.

Lack of implementation isn’t only a state and local government problem. Despite evidence that screening patients for suicidal thoughts during medical visits , health professionals are not mandated to do so.

Many doctors find suicide screening daunting because they have limited time and insufficient training and because they aren’t comfortable discussing suicide, said Janet Lee, an adolescent medicine specialist and associate professor of pediatrics at the Lewis Katz School of Medicine at Temple University.

“I think it is really scary and kind of astounding to think if something is a matter of life and death how somebody can’t ask about it,” she said.

The use of other measures has also been inconsistent. Crisis intervention services are core to the national strategies, yet many states haven’t built standardized systems.

Besides being fragmented, crisis systems, such as mobile crisis units, can vary from state to state and county to county. Some mobile crisis units use telehealth, some operate 24 hours a day and others 9 to 5, and some use local law enforcement for responses instead of mental health workers.

Similarly, the fledgling 988 Suicide & Crisis Lifeline faces similar, serious problems.

Only 23% of Americans are familiar with 988 and there’s a significant knowledge gap about the situations people should call 988 for, according to a conducted by the National Alliance on Mental Illness and Ipsos.

Most states, territories, and tribes have also not yet permanently funded 988, which was launched nationwide in July 2022 and about $1.5 billion in federal funding, according to the Substance Abuse and Mental Health Services Administration.

Anita Everett, director of the Center for Mental Health Services within SAMHSA, said her agency is running an awareness campaign to promote the system.

Some states, including Colorado, are taking other steps. There, state officials installed financial incentives for implementing suicide prevention efforts, among other patient safety measures, through the state’s Hospital Quality Incentive Payment Program. The program hands out about $150 million a year to hospitals for good performance. In the last year, 66 hospitals improved their care for patients experiencing suicidality, according to Lena Heilmann, director of the Office of Suicide Prevention at the Colorado Department of Public Health and Environment.

Experts hope other states will follow Colorado’s lead.

And despite the slow movement, Mehta sees bright spots in the latest strategy and action plan.

Although it is too late to save Raj, “addressing the social drivers of mental health and suicide and investing in spaces for people to go to get help well before a crisis gives me hope,” Mehta said.

Cheryl Platzman Weinstock’s reporting is supported by a grant from the National Institute for Health Care Management Foundation.

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BRIDGEPORT, Conn. — Milagros Aquino was trying to find a new place to live and had been struggling to get used to new foods after she moved to Bridgeport from Peru with her husband and young son in 2023.

When Aquino, now 31, got pregnant in May 2023, “instantly everything got so much worse than before,” she said. “I was so sad and lying in bed all day. I was really lost and just surviving.”

Aquino has lots of company.

Perinatal depression affects as many as 20% of women in the United States during pregnancy, the postpartum period, or both, . In some states, anxiety or depression afflicts nearly a quarter of new mothers or pregnant women.

Many women in the U.S. go untreated because there is no widely deployed system to screen for mental illness in mothers, despite widespread recommendations to do so. Experts say the lack of screening has driven higher rates of mental illness, suicide, and drug overdoses that are now the leading causes of death in the first year after a woman gives birth.

“This is a systemic issue, a medical issue, and a human rights issue,” said Lindsay R. Standeven, a perinatal psychiatrist and the clinical and education director of the Johns Hopkins Reproductive Mental Health Center.

Standeven said the root causes of the problem include racial and socioeconomic disparities in maternal care and a lack of support systems for new mothers. She also pointed a finger at a shortage of mental health professionals, insufficient maternal mental health training for providers, and insufficient reimbursement for mental health services. Finally, Standeven said, the problem is exacerbated by the absence of national maternity leave policies, and the access to weapons.

Those factors helped drive a in postpartum depression from 2010 to 2021, according to the American Journal of Obstetrics & Gynecology.

For Aquino, it wasn’t until the last weeks of her pregnancy, when she signed up for acupuncture to relieve her stress, that a social worker helped her get care through the Emme Coalition, which connects girls and women with financial help, mental health counseling services, and other resources.

Mothers diagnosed with perinatal depression or anxiety during or after pregnancy are at about three times the risk of suicidal behavior and six times the risk of suicide compared with mothers without a mood disorder, according to recent U.S. and international studies in and .

The toll of the maternal mental health crisis is particularly acute in rural communities that have become maternity care deserts, as small hospitals close their labor and delivery units because of plummeting birth rates, or because of financial or staffing issues.

This week, the Maternal Mental Health Task Force — co-led by the Office on Women’s Health and the Substance Abuse and Mental Health Services Administration and formed in September to respond to the problem — that could serve as hubs of integrated care and birthing facilities by building upon the services and personnel already in communities.

The task force will soon determine what portions of the plan will require congressional action and funding to implement and what will be “low-hanging fruit,” said Joy Burkhard, a member of the task force and the executive director of the nonprofit Policy Center for Maternal Mental Health.

Burkhard said equitable access to care is essential. The task force recommended that federal officials identify areas where maternity centers should be placed based on data identifying the underserved. “Rural America,” she said, “is first and foremost.”

There are shortages of care in “unlikely areas,” including Los Angeles County, where some maternity wards have recently closed, said Burkhard. Urban areas that are underserved would also be eligible to get the new centers.

“All that mothers are asking for is maternity care that makes sense. Right now, none of that exists,” she said.

Several pilot programs are designed to help struggling mothers by training and equipping midwives and doulas, people who provide guidance and support to the mothers of newborns.

In Montana, rates of maternal depression before, during, and after pregnancy are higher than the national average. From 2017 to 2020, approximately 15% of mothers experienced postpartum depression and 27% experienced perinatal depression, according to the The state had the sixth-highest maternal mortality rate in the country in 2019, when it received a federal grant to begin training doulas.

To date, the program has trained 108 doulas, many of whom are Native American. Native Americans make up . Indigenous people, particularly those in rural areas, have of severe maternal morbidity and mortality compared with white women, according to a study in Obstetrics and Gynecology.

Stephanie Fitch, grant manager at Montana Obstetrics & Maternal Support at Billings Clinic, said training doulas “has the potential to counter systemic barriers that disproportionately impact our tribal communities and improve overall community health.”

and Washington, D.C., have Medicaid coverage for doula care, according to the National Health Law Program. They are California, Florida, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, Oklahoma, Oregon, Rhode Island, and Virginia. Medicaid pays for about in the U.S., according to the Centers for Disease Control and Prevention.

Jacqueline Carrizo, a doula assigned to Aquino through the Emme Coalition, played an important role in Aquino’s recovery. Aquino said she couldn’t have imagined going through such a “dark time alone.” With Carrizo’s support, “I could make it,” she said.

Genetic and environmental factors, or a past mental health disorder, can increase the risk of depression or anxiety during pregnancy. But mood disorders can happen to anyone.

Teresa Martinez, 30, of Price, Utah, had struggled with anxiety and infertility for years before she conceived her first child. The joy and relief of giving birth to her son in 2012 were short-lived.

Without warning, “a dark cloud came over me,” she said.

Martinez was afraid to tell her husband. “As a woman, you feel so much pressure and you don’t want that stigma of not being a good mom,” she said.

In recent years, programs around the country have started to help doctors recognize mothers’ mood disorders and learn how to help them before any harm is done.

One of the most successful is the Massachusetts Child Psychiatry Access Program for Moms, which began a decade ago and has since spread to 29 states. The program, supported by federal and state funding, provides tools and training for physicians and other providers to screen and identify disorders, triage patients, and offer treatment options.

But the expansion of maternal mental health programs is taking place amid sparse resources in much of rural America. Many programs across the country have run out of money.

The federal task force proposed that Congress fund and create consultation programs similar to the one in Massachusetts, but not to replace the ones already in place, said Burkhard.

In April, Missouri became the latest state to adopt the Massachusetts model. Women on Medicaid in Missouri are 10 times as likely to die within one year of pregnancy as those with private insurance. From 2018 through 2020, an average of 70 Missouri women died each year while pregnant or within one year of giving birth, according to state .

Wendy Ell, executive director of the Maternal Health Access Project in Missouri, called her service a “lifesaving resource” that is free and easy to access for any health care provider in the state who sees patients in the perinatal period.

About 50 health care providers have signed up for Ell’s program since it began. Within 30 minutes of a request, the providers can consult over the phone with one of three perinatal psychiatrists. But while the doctors can get help from the psychiatrists, mental health resources for patients are not as readily available.

The task force called for federal funding to train more mental health providers and place them in high-need areas like Missouri. The task force also recommended training and certifying a more diverse workforce of community mental health workers, patient navigators, doulas, and peer support specialists in areas where they are most needed.

A new in reproductive psychiatry is designed to help psychiatry residents, fellows, and mental health practitioners who may have little or no training or education about the management of psychiatric illness in the perinatal period. A small that the curriculum significantly improved psychiatrists’ ability to treat perinatal women with mental illness, said Standeven, who contributed to the training program and is one of the study’s authors.

Nancy Byatt, a perinatal psychiatrist at the University of Massachusetts Chan School of Medicine who led the launch of the Massachusetts Child Psychiatry Access Program for Moms in 2014, said there is still a lot of work to do.

“I think that the most important thing is that we have made a lot of progress and, in that sense, I am kind of hopeful,” Byatt said.

Cheryl Platzman Weinstock’s reporting is supported by a grant from the National Institute for Health Care Management Foundation.

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Amanda MorningStar has watched her children struggle with mental health issues, including suicidal thoughts. She often wonders why.

“We’re family-oriented and we do stuff together. I had healthy pregnancies. We’re very protective of our kids,” said MorningStar, who lives in Heart Butte, Montana, a town of about 600 residents on the Blackfeet Indian Reservation.

Yet despite her best efforts, MorningStar said, her family faces a grim reality that touches Native American communities nationwide. About a year ago, her 15-year-old son, Ben, was so grief-stricken over his cousin’s suicide and two classmates’ suicides that he tried to kill himself.

“Their deaths made me feel like part of me was not here. I was gone. I was lost,” said Ben MorningStar.

He spent more than a week in an inpatient mental health unit, but once home, he was offered sparse mental health resources.

Non-Hispanic Indigenous people in the United States than any other racial or ethnic group, according to the Centers for Disease Control and Prevention. The suicide rate among Montana’s Native American youth is more than five times the statewide rate for the same age group, according to the . Montana ranked among states for suicide deaths in 2020, and 10% of all suicides in the state from 2017 through 2021 were among Native Americans, even though they represent only 6.5% of the state’s population.

Despite decades of research into suicide prevention, suicide rates among Indigenous people have , especially among Indigenous people ages 10 to 24, according to the CDC. Experts say that’s because the national strategy for suicide prevention isn’t culturally relevant or sensitive to Native American communities’ unique values.

Suicide rates have increased among other , too, but to lesser degrees.

Systemic issues and structural inequities, including underfunded and under-resourced services from the federal Indian Health Service, also hamper suicide prevention in Indigenous communities. “I worried who was going to keep my son safe. Who could he call or reach out to? There are really no resources in Heart Butte,” said Amanda MorningStar.

Ben MorningStar said he is doing better. He now knows not to isolate himself when problems occur and that “it is OK to cry, and I got friends I can go to when I have a bad day. Friends are better than anything,” he said.

His twice-a-month, 15-minute virtual telehealth behavioral therapy visits from IHS were recently reduced to once a month.

Mary Cwik, a psychologist and senior scientist at the Center for Indigenous Health at Johns Hopkins Bloomberg School of Public Health in Baltimore, said the systemic shortcomings MorningStar has witnessed are symptoms of a national strategy that isn’t compatible with Indigenous value systems.

“It is not clear that the creation of the national strategy had Indigenous voices informing the priorities,” Cwik said.

The cause of high suicide rates in Indigenous communities is complex. Native Americans often live with the weight of more than other populations — things such as emotional, physical, and sexual abuse, intimate partner violence, substance misuse, mental illness, parental separation or divorce, incarceration, and poverty.

Those adverse experiences stack upon caused by racial discrimination, colonization, forced relocation, and government-sanctioned abduction to boarding schools that persisted until the 1970s.

“There’s no way that communities shaped by these forces for so long will get rid of their problems fast by medical services. A lot of people in Indian Country struggle to retain hope. It’s easy to conclude that nothing can fix it,” said Joseph P. Gone, a professor of anthropology and global health and social medicine at Harvard University and member of the Gros Ventre (Aaniiih) tribal nation of Montana.

Most tribal nations are interested in collaborative research, but funding for such work is hard to come by, said Gone. So is funding for additional programs and services.

Stephen O’Connor, who leads the suicide prevention research program at the Division of Services and Intervention Research at the National Institute of Mental Health, said, “Given the crisis of suicide in Native American populations, we need more funding and continued sustained funding for research in this area.”

Getting grants for scientific research from NIMH, which is part of the National Institutes of Health, can be challenging, especially for smaller tribes, he said.

Officials at the NIMH and the Substance Abuse and Mental Health Services Administration said that they continue to build research partnerships with tribal nations and that they recently launched new grants and multiple programs that are culturally informed and evidence-based to reduce suicide in tribal communities.

NIMH researchers are even adjusting a commonly used suicide screening tool to incorporate more culturally appropriate language for Indigenous people.

Teresa Brockie, an associate professor at Johns Hopkins School of Nursing, is one of a small but growing number of researchers, many of whom are Indigenous, who study suicide prevention and intervention strategies that respect Indigenous beliefs and customs. Those strategies include smudging — the practice of burning medicinal plants to cleanse and connect people with their creator.

Without this understanding, research is hampered because people in tribal communities have “universal mistrust of health care and other colonized systems that have not been helpful to our people or proven to be supportive,” said Brockie, a member of Fort Belknap reservation’s Aaniiih Tribe.

Brockie is leading studying Indigenous people at Fort Peck. The project aims to reduce suicide risk by helping parents and caregivers deal with their own stress and trauma and develop positive coping skills. It’s also working to strengthen children’s tribal identity, connectivity, and spirituality.

In 2015, she reported on a study she led in 2011 to collect suicide data at the Fort Peck reservation in northeastern Montana. She found that adverse childhood experiences on suicide risk and also that tribal identity, strong connections with friends and family, and staying in school were protective against suicide.

In Arizona, Cwik is collaborating with the White Mountain Apache Tribe to help leaders there evaluate the impact of a comprehensive suicide surveillance system they created. So far, the program has by 38.3 % and the rate among young people ages 15 to 24 by 23%, according to the American Public Health Association.

Several tribal communities are attempting to implement a similar system in their communities, said Cwik.

Still, many tribal communities rely on limited mental health resources available through the Indian Health Service. One person at IHS is tasked with addressing suicide across almost 600 tribal nations.

Pamela End of Horn, a social worker and national suicide prevention consultant at IHS, said the Department of Veterans Affairs “has a suicide coordinator in every medical center across the U.S., plus case managers, and they have an entire office dedicated to suicide prevention. In Indian Health Service it is just me and that’s it.”

End of Horn, a member of the Oglala Lakota Sioux Tribe of the Pine Ridge Indian Reservation in South Dakota, blames politics for the discrepancy.

“Tribal leaders are pushing for more suicide prevention programs but lack political investment. The VA has strong proactive activities related to suicide and the backing of political leaders and veterans’ groups,” she said.

It is also hard to get mental health professionals to work on remote reservations, while VA centers tend to be in larger cities.

Even if more mental health services were available, they can be stigmatizing, re-traumatizing, and culturally incongruent for Indigenous people.

Many states are using creative strategies to stop suicide. A pilot project by the Rural Behavioral Health Institute screened more than 1,000 students in 10 Montana schools from 2020 to 2022. The governor of Montana is hoping to use state money to expand mental health screening for all schools.

Experts say the kinds of strategies best suited to prevent suicide among Native Americans should deliver services that reflect their diversity, traditions, and cultural and language needs.

That’s what Robert Coberly, 44, was searching for when he needed help.

Coberly began having suicidal thoughts at 10 years old.

“I was scared to live and scared to die. I just didn’t care,” said Coberly, who is a member of the Tulalip Tribes.

He suffered in private for nearly a decade until he almost died in a car crash while driving drunk. After a stay at a rehabilitation center, Coberly remained stable. Years later, though, his suicidal thoughts came rushing back when one of his children died. He sought treatment at a behavioral health center where some of the therapists were Indigenous. They blended Western methodologies with Indigenous customs, which, he said, “I was craving and what I needed.”

Part of his therapy included going to a sweat lodge for ritual steam baths as a means of purification and prayer.

Coberly was a counselor for the Native and Strong Lifeline, the first 988 crisis line for Indigenous people. He is now one of the crisis line tribal resource specialists connecting Indigenous people from Washington state with the resources they need.

“It’s about time we had this line. To be able to connect people with resources and listen to them is something I can’t explain except that I was in a situation where I wanted someone to hear me and talk to,” said Coberly.

Amanda MorningStar said she still worries about her son night and day, but he tries to reassure her.

“I go to sleep and wake up the next day to keep it going,” Ben MorningStar said. “I only get one chance. I might as well make the best of it.”

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Jason Lance thought Jan. 21, 2010, was a day like any other until the call came.

He had dropped off his 9-year-old son, Montana, at Stewart’s Creek Elementary School in The Colony, Texas, that morning.

“There were no problems at home. He was smart. He wore his heart on his sleeve and he talked and talked and talked,” said Lance. It was “the same old, same old normal day. There were kisses and goodbyes and he said, ‘I love you, Daddy.’”

A few hours later, school officials called to say Montana had died by suicide while locked in the nurse’s bathroom.

“I knew he had some issues going on in school, but I never seen it coming,” said Lance. His shock and grief were complicated by the realization that there may have been more signs his son was struggling.

As children across the country step back into school routines this fall, it is important to pay attention to their mental health as well as their academics. Suicide ranks as either the seventh- or eighth-leading cause of death among children ages 5 to 11, according to the Centers for Disease Control and Prevention and . And numbers show the rates among younger kids appear to have increased in the past decade, especially among Black males.

A growing body of research shows that “historically we thought that suicide is a problem of teens and adults, but younger children are expressing similar thoughts that may have been ignored before,” said Paul Lipkin, a pediatrician at the Kennedy Krieger Institute in Baltimore and a specialist in developmental disabilities such as autism.

This has many experts calling for lowering the screening age for suicide ideation in children and moving to develop more effective early suicide risk detection and targeted prevention strategies. The broad approach includes pediatricians, teachers, and parents working with children at a young age to build their resilience and identify and manage their stress.

Studies have found that about death and killing oneself from TV or other media, discussions with other children, or exposure to death from a family or community loss.

“Pediatric suicide wasn’t on our radar decades ago and maybe was underreported,” said Holly Wilcox, president of the International Academy of Suicide Research and a professor at the Johns Hopkins Bloomberg School of Public Health in Baltimore. “The truth is that now we can do stuff about it.”

It is quite likely the 136 reported suicides from 2001 to 2021 among 5- to 9-year-olds were an undercount.

“Counts are often incomplete, and causes of death may be pending investigation resulting in an underestimate relative to final counts,” said Margaret Warner, a senior epidemiologist at the CDC.

The problems with those numbers are important because, Warner said, “if we are missing deaths, or don’t have all the information leading to them, we can’t properly develop programs to prevent future deaths.”

That’s why there’s also an ongoing national effort by coroners and medical examiners to improve the quality and consistency of pediatric death investigations.

Leaders in suicide prevention hope this wide spotlight on pediatric suicide will also help curtail the rising suicide rate among people ages 10 to 24 in the U.S. since suicide is the of death in that age group, according to the CDC.

Some of the increase in mental health issues among children has been attributed to the isolation and lack of school structure during the pandemic. Beginning in April 2020, pediatric emergency room visits for children 5 to 11 increased approximately 24%, according to a from November 2020.

Other factors, such as being neurodivergent or having a psychiatric disorder, can make a child more vulnerable to suicide.

A study published in also found that being the victim or perpetrator of bullying is a risk factor for suicide, even when researchers controlled for other risk factors.

Montana Lance was diagnosed with attention-deficit/hyperactivity disorder, as well as dyslexia, and often was the target of bullying at school.

Officials at the Lewisville Independent School District declined to comment on Montana’s death. His parents filed a lawsuit against the school district, but it was dismissed, and the district was found not liable for his death.

Suicide is complex, but recent studies have found that there are things parents, teachers, pediatricians, and caregivers can do to help protect children from it.

Lisa Horowitz, a pediatric psychologist and staff scientist at the National Institute of Mental Health, said, “It’s never too early to start a conversation with kids about recognizing mental health distress and doing what we can do to help them have better coping strategies and foster resilience.”

in children can help buffer them in times of stress, according to a study published in 2022 in Frontiers of Psychiatry.

“I don’t want people to panic but just want them to be vigilant about their children,” said Horowitz.

Sometimes that vigilance can be “tricky” because depression may look different in younger kids. They may act out, be more irritable, and not manifest their symptoms in the same way as teens and adults, Wilcox said.

“We don’t have enough studies on how best to identify preteens and children at risk for suicide. Oftentimes you just have to trust your gut about these things,” she said.

If a child is upset, parents should ask them questions about what they’re experiencing, said Tami D. Benton, psychiatrist-in-chief, executive director, and chair of the Department of Child and Adolescent Psychiatry and Behavioral Sciences at Children’s Hospital of Philadelphia.

“Parents shouldn’t talk kids out of their feelings or give them examples of when it happened to them, or minimize their feelings. It puts them down,” she said.

Parents and children should come up with a plan together, but also teach their children that they can master these situations, said Benton.

When parents get stuck about what to do in difficult situations, they should consult with their child’s pediatrician.

In March, the American Academy of Pediatrics recommended universal screening for suicide risk in all children 12 and older and when clinically indicated for kids 8 to 11. There aren’t any screening tools validated for use in children under 8. But Horowitz said younger children can still be assessed and evaluated for suicide risk.

Schools can also play an important role in suicide prevention.

Meghan Feby, a school counselor in the Colonial School District in New Castle, Delaware, said, “I am the sole school counselor in my building. It is a daunting task. That’s why there are supports in place that have eyes where I can’t have eyes … on school computers. Employing software strategies like GoGuardian Beacon can really help fill in gaps and supports.”

The software captures keywords and phrases that might indicate a child is thinking about suicide and has already been used to intervene when children using district computers displayed concerning behavior. It is monitoring activities on school computers used by more than 6.7 million public school students in kindergarten through 12th grade.

Some schools said they are having problems implementing software like this because some parents find it intrusive.

Many schools use the Good Behavior Game, a decades-old behavior management intervention for kids in first and second grades, and it has been used in higher grades. The team-oriented classroom curriculum uses peer pressure to stimulate students to be attentive and engaged and work together. Researchers such as Wilcox have studied the extensive participation of thousands of students and found it reduced suicidal thoughts and behaviors.

Children who have played the game as young adults to report suicidal thoughts and about a third less likely to report a suicide attempt.

Lance said that the day Montana died by suicide changed his life forever.

“You’re not supposed to bury your children. They’re supposed to bury you,” he said. “All this attention on the mental health status of children these days is not going to bring my child back, but it can stop another family from suffering.”

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If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

Aimee Quicke has made repeated trips to emergency rooms, hospitals, behavioral health facilities, and psychiatric lockdowns for mental health crises — including suicidal thoughts — since she was 11.

The 40-year-old resident of Le Mars, Iowa, has bipolar and obsessive-compulsive disorders. “Some of the visits were helpful and some were not,” she said. “It was like coming in and going out and just nothing different was happening.”

Then she heard about Rhonda’s House, a rural peer respite program that opened on the other side of the state in 2018, through acquaintances in her community.

That facility, and dozens of others like it established nationwide over the past 20 years, offers a short-term, homelike, nurturing environment for people who are experiencing a mental health crisis but don’t need immediate medical attention. At respites, patients are treated like guests, proponents say, and can feel heard and keep their dignity without having to relinquish their clothes and other belongings.

During her weeklong stay at Rhonda’s House, which founder and executive director Todd Noack referred to as “a bed-and-breakfast facility for emotional distress,” Quicke made many breakthroughs, working on her self-esteem and gaining better coping skills. If she hadn’t found the program, she said, “I don’t think I would have come out of 2020.”

Public health professionals say respite facilities can potentially play a big role in addressing a national mental health crisis that accelerated dramatically during the covid-19 pandemic, especially when it comes to suicide prevention.

“It’s a really important piece of the larger puzzle of how to improve health care and reduce suicide risk, because there is a ‘traffic jam’ in suicide prevention,” said Jane Pearson, chair of the National Institute of Mental Health Suicide Research Consortium.

Respites rely on trained peers to provide care, and often serve patients who might otherwise visit overburdened ERs, psychiatric institutions, and therapists. Today there are 42 community-based respite programs spread across 14 states, including new ones opened recently in Tacoma, Washington, and Grand Rapids, Michigan. Most are nonprofits governed by a patchwork of state guidelines, and they’re funded by a mixture of local, state, and federal grants.

Experts say the programs fill a void, though there is little hard data on their effectiveness. Paolo del Vecchio, director of the Office of Recovery at the federal Substance Abuse and Mental Health Services Administration, said peer-run respites have proven themselves as an “evidence-based model of care,” with positive effects including reduced hospitalizations and increased engagement with community support services.

A 2015 study published online in the journal Psychiatric Services found that people who sought respite were to use inpatient emergency services than non-respite users.

Still, del Vecchio said, more research is needed to analyze how the programs are working and troubleshoot problems. SAMHSA is conducting a cost-benefit analysis of respite programs that officials hope to release this summer.

Pearson said she would like to see more research on who uses respites, how they are advertised, clients’ reasons for seeking them, and whether they deliver what they promise.

Respites can be especially important in rural America, where suicides increased 46% from 2000 to 2020, compared with 27.3% in urban areas, according to the Centers for Disease Control and Prevention. Rural residents also have 1½ times the rates of ER visits for self-harm as urban residents.

Del Vecchio hopes greater awareness can help bring the promising respite approach to the states with the highest suicide rates, including Wyoming, Montana, Alaska, and New Mexico.

Rhonda’s House, in Dewitt, Iowa, has provided care to 392 people over the past five years, and recently moved into a three-story, five-bedroom house with two baths. Peer specialists in Iowa must complete 40 hours of training plus six hours of ethics counseling, and then work 500 hours to become eligible to take a state certification test.

For Quicke, Rhonda’s House was a lifesaver during a brutal 2020. The pandemic had isolated her from her support system, her brother-in-law died, her long-term partner moved out, and her mother had open-heart surgery.

“There was a lot of chaos. A lot of family fights broke out. That’s when I took off — packed a bag and left for respite,” said Quicke. “There was nowhere else closer to go.”

She drove six hours from her home to Rhonda’s House, where she found 24-hour help that you “just can’t get from an emergency room or hospital.”

Unlike traditional hospital staffers, peers are available to speak with guests whenever they are needed, which Quicke appreciated since she has “a lot of panic and anxiety in the night and it’s frightful.” She also found it easy and comforting to speak with peers with “lived experience,” or firsthand experience with mental health challenges.

Allowing people to reach out for help without being judged is a crucial feature of the respite model, said Paul Pfeiffer, a psychiatrist at the University of Michigan’s medical center. He cautioned against regulations that would make them more like hospitals, noting that many people in trouble avoid getting help because they fear being locked up in a psychiatric facility.

Quicke said she learned a lot during her stay at Rhonda’s House. “I always thought I was co-dependent. I learned I just need me and my dogs. I learned wellness tools and that I can be strong and resourceful and resilient,” she said. She described being more conscious of her triggers and said she had “more routines to help with sleep hygiene.”

When Quicke left, respite staffers connected her with community resources close to her home, near the Nebraska border. They also encouraged her to call if she needed help again and told her she could return for another stay after 60 days — giving her time to work through her challenges and freeing up space for others in the meantime.

“Peer respite works 8 out of 10 times,” said Noack, the executive director. “Some people do have to leave to get another level of care, but nothing is ever perfect.”

The average cost of staying at Rhonda’s House is $428 a day — far less than the thousands of dollars a hospital stay typically costs. Noack’s respite does not bill insurance but covers the cost with state and regional contracts, as well as donations, like many other respites.

Some respites receive Medicaid funding. As this type of care grows, more states will explore Medicaid and other funding sources, said del Vecchio.

A few weeks ago Quicke became discouraged after a job rejection. She thought about going back to Rhonda’s House but said she channeled what she learned there during her stay.

“I was able to use my coping skills to get through it,” she said.

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“I had [acute] paranoia and depression off the roof,” said Marcell, 46, who asked to be identified only by his first name because he wanted to maintain confidentiality about some aspects of his illness.

Marcell’s depression was so profound, he said, he didn’t want to move and was considering suicide.

“Things were getting overwhelming and really rough. I wanted to end it,” he said.

Marcell, diagnosed with schizoaffective disorder seven years ago, had been this route before but never during a pandemic. The Detroit area was a coronavirus hot spot, slamming hospitals, attracting concerns from federal public health officials and recording more than 1,000 deaths in Wayne County as of May 28. Michigan ranks fourth among states for deaths from COVID-19.

The crisis enveloping the hospitals had a ripple effect on mental health programs and facilities. The emergency room was trying to get non-COVID patients out as soon as possible because the risk of infection in the hospital was high, said Jaime White, director of clinical development and crisis services for Hegira Health, a nonprofit group offering mental health and substance abuse treatment programs. But the options were limited.

Still, the number of people waiting for beds at Detroit’s crisis centers swelled. Twenty-three people in crisis had to instead be cared for in a hospital.

This situation was hardly unique. Although mental health services continued largely uninterrupted in areas with low levels of the coronavirus, behavioral health care workers in areas hit hard by COVID-19 were overburdened. Mobile crisis teams, residential programs and call centers, especially in pandemic hot spots, had to reduce or close services. Some programs were plagued by shortages of staff and protective supplies for workers.

At the same time, people battling mental health disorders became more stressed and anxious.

“For people with preexisting mental health conditions, their routines and ability to access support is super important. Whenever additional barriers are placed on them, it could be challenging and can contribute to an increase in symptoms,” said White.

After eight hours in the emergency room, Marcell was transferred to , a community outreach program for psychiatric emergencies for Wayne County Medicaid patients.

“We try to get patients like him into the lowest care possible with the least restrictive environment,” White said. “The quicker we could get him out, the better.”

Marcell was stabilized at COPE over the next three days, but his behavioral health care team couldn’t get him a bed in one of two local residential crisis centers operated by Hegira. Social distancing orders had reduced the beds from 20 to 14, so Marcell was discharged home with a series of scheduled services and assigned a service provider to check on him.

However, Marcell’s symptoms ― suicidal thoughts, depression, anxiety, auditory hallucinations, poor impulse control and judgment ― persisted. He was not able to meet face-to-face with his scheduled psychiatrist due to the pandemic and lack of telehealth access. So, he returned to COPE three days later. This time, the staff was able to find him a bed immediately at a Hegira residential treatment program, Boulevard Crisis Residential in Detroit.

Residents typically stay for six to eight days. Once they are stabilized, they are referred elsewhere for more treatment, if needed.

Marcell ended up staying for more than 30 days. “He got caught in the pandemic here along with a few other people,” said Sherron Powers, program manager. “It was a huge problem. There was nowhere for him to go.”

Marcell couldn’t live with his girlfriend anymore. Homeless shelters were closed and substance abuse programs had no available beds.

“The big problem here is that all crisis services are connected to each other. If any part of that system is disrupted you can’t divert a patient properly,” said Travis Atkinson, a behavioral consultant with TBD Solutions, which collaborated on a survey of providers with the American Association of Suicidology, the Crisis Residential Association and the National Association of Crisis Organization Directors.

White said the crisis took a big toll on her operations. She stopped her mobile crisis team on March 14 because, she said, “we wanted to make sure that we were keeping our staff safe and our community safe.”

Her staff assessed hospital patients, including Marcell, by telephone with the help of a social worker from the emergency room.

People like Marcell have struggled during the coronavirus crisis and continue to face hurdles because emergency preparedness measures didn’t provide enough training, funds or thought about the acute mental health issues that could develop during a pandemic and its aftermath, said experts.

“The system isn’t set up to accommodate that kind of demand,” said Dr. Brian Hepburn, a psychiatrist and executive director of the National Association of State Mental Health Program Directors.

“In Detroit and other hard-hit states, if you didn’t have enough protective equipment you can’t expect people to take a risk. People going to work can’t be thinking ‘I’m going to die,’” said Hepburn.

For Marcell, “it was bad timing to have a mental health crisis,” said White, the director at Hegira.

At one time Marcell, an African American man with a huge grin and a carefully trimmed goatee and mustache, had a family and a “pretty good job,” Marcell said. Then “it got rough.” He made some bad decisions and choices. He lost his job and got divorced. Then he began self-medicating with cocaine, marijuana and alcohol.

By the time he reached the residential center in Detroit on April 1, he was at a low point. “Schizoaffective disorder comes out more when you’re kicked out of the house and it increases depression,” said Powers, the program manager who along with White was authorized by Marcell to talk about his care. Marcell didn’t always take his medications and his use of illicit drugs magnified his hallucinations, she said.

While in the crisis center voluntarily, Marcell restarted his prescription medications and went to group and individual therapy. “It is a really good program,” he said while at the center in early May. “It’s been one of the best 30 days.”

Hepburn said the best mental health programs are flexible, which allows them more opportunities to respond to problems such as the pandemic. Not all programs would have been able to authorize such a long stay in residential care.

Marcell was finally discharged on May 8 to a substance abuse addiction program. “I felt good about having him do better and better. He had improved self-esteem to get the help he needed to get back to his regular life,” Powers said.

But Marcell left the addiction program after only four days.

“The [recovery] process is so individualized and, oftentimes, we only see them at one point in their journey. But, recovering from mental health and substance use disorders is possible. It can just be a winding and difficult path for some,” said White.

Seeking Help

If you or someone you know is in immediate danger, call 911. Below are other resources for those needing help:

— National Helpline: 1-800-662-HELP (4357) or .

— National Suicide Prevention Lifeline: 1-800-273-TALK (8255).

— Disaster Distress Helpline: 1-800-985-5990 or text TalkWithUs to 66746.

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The immigrant from India believed her husband when he said that if she wasn’t gone by the time he got to their Georgia home in 10 minutes, he would kill her.

She said her husband and his family, who are also immigrants, abused her throughout their marriage, beating her with a belt, pouring hot water on her, cutting her, and pushing her head through a wall.

“Several times I tried to escape, but they found me and brought me back home,” said the woman, who is in the country illegally and spoke on the condition of anonymity because she is afraid being identified would harm her chances of gaining legal status.

With no time to run after her husband’s call in July 2020, she dialed 911, even though she knew she could be deported. The police arrived to find the husband threatening her with a knife in front of their young children, she recalled. He was arrested but not prosecuted, she said.

The woman and her children sought services from the Tahirih Justice Center, a national nonprofit organization that serves immigrant survivors of gender-based violence. She is still winding through the immigration process five years later.

Besides immigrants’ increased vulnerability to sexual violence, they face a host of mental health and physical challenges, researchers say. They have high rates of post-traumatic stress disorder, depression, suicide, and anxiety, according .

“Personally, I know anxiety related to the current political climate is precipitating expensive emergency room visits and negatively impacting people’s ability to get to work and make a living,” said Nicole E. Warren, a nurse midwife and an associate professor at the Johns Hopkins School of Nursing in Baltimore.

Immigrants without legal status also face increased rates of chronic conditions and higher death rates from preventable diseases due to their limited access to health care and their fear of seeking it, advocates say.

“One of our clients was so afraid to leave her home that she avoided seeking medical care during her pregnancy, out of fear of interacting with ICE,” said Miriam Camero, director of client advocacy, social services, at Tahirih.

Food banks have reported that many immigrants in need of food assistance have stopped coming, for fear of deportation.

It has always been difficult for people without legal immigration status to get help when they need it. The Trump administration’s crackdown on people in the country illegally has intensified the pressure. The situation has also hampered the advocates and attorneys who defend their rights.

“We’re working extra hours to do all the work,” said Vanessa Wilkins, executive director of Tahirih’s office in Atlanta. “The safety planning and added protection that clients might need, including documents just to make sure they are safe, can definitely make you feel overwhelmed.”

U Visas

For domestic abuse survivors without legal status, like the woman from India, going to the authorities seems more fraught amid the immigration crackdown, said Maricarmen Garza, chief counsel of the American Bar Association Commission on Domestic & Sexual Violence.

“There are just no guarantees,” Garza said, “especially with how law enforcement is intertwined in enforcing immigration law.”

In more than half of states, U.S. Immigration and Customs Enforcement agents can collaborate by formal written agreements with state and local law enforcement agencies to identify and remove people in the country illegally. Advocates say this can interfere with victims’ efforts to get a certificate to file for a “U visa,” which would allow them to live and work in the U.S. with the possibility of lawful permanent residency.

The battered woman from India recalls police telling her that if she did not press charges, she could get a certificate for a U visa. She agreed to their suggestion but recalls the anxiety of filing about five abuse reports over two years to get the certificate. “I got panic attacks just writing them down, because it meant I was reliving the situations again,” she said.

When asked for comment about the difficulties immigrant domestic violence victims face, White House spokesperson Abigail Jackson touted President Donald Trump’s efforts to crack down on illegal immigration. “The president’s successful effort to deport criminal illegal aliens is making all victims safer and ensuring they will never again be harmed by dangerous criminal illegal aliens,” Jackson said in a statement. She said “allegations without evidence” that immigrants have been told to drop charges “should not be taken seriously.”

Immigrant women without legal status can be particularly vulnerable to abuse and exploitation because of language barriers, as well as cultural and social isolation,

According to , lifetime rates of abuse by intimate partners range up to 93% in some immigrant groups, compared with about 41% of U.S.-born women experiencing such abuse in their lifetime.

As the Trump administration reshapes the country’s immigration system, survivors of violence who entered the country illegally have a tough time proving their abuse and trauma to get relief, advocates say.

A refugee health and asylum program at Johns Hopkins in Baltimore provides immigrant victims of abuse with free forensic evaluations to support their claims for humanitarian relief, including applications for U visas.

Warren, the program’s associate director for women’s health, said that in the past, a written affidavit of the clinic’s findings was enough to corroborate an applicant’s legal accounts of past trauma.

“Now, we are getting requests for our in-person testimony,” Warren said.

Application Backlogs

The woman from India applied for a visa after she received a certificate from law enforcement allowing her to do so in 2023. Hers is one of nearly 11.6 million pending visa applications, — the highest volume of cases ever recorded by U.S. Citizenship and Immigration Services. The number of pending U visa applications is 415,000, according to the agency.

Only about 10,000 U visas are issued per year, and it can take more than seven years to process applications, Garza said.

Adding to the pressure, the Trump administration has reduced the availability of Section 8 housing, which helps low-income individuals and others pay their rent. , people without legal authorization to be in the United States are not eligible to receive rental help over U.S. citizens.

“If Tahirih wasn’t behind me, I could be homeless,” said the woman, who said she can afford only half her rent.

Victims’ advocates say they are working harder than ever to support their clients but are stretched thin as they face federal funding cuts and increased demand.

The Tahirih center reported a 200% increase in call volume in the four months after Trump took office, compared with the same period last year.

“At the end of the day there are a lot of emails and a lot of people we aren’t able to reach as quickly as in the past,” said Casey Carter Swegman, the center’s director of public policy.

To reach immigrant survivors of abuse who are afraid to come forward, advocates are “getting back to basics,” said Joanna Otero-Cruz, executive director and president of the Philadelphia group Women Against Abuse.

“We’re doing grassroots outreach to hairdressers and other small-business owners,” she said. “They’re the eyes and ears for us.”

In Riverhead, New York, a 38-year-old woman who emigrated from El Salvador said she has twice been the victim of domestic abuse but was too scared to report it to police.

She said the second assault was by a man for whom she cooked and cleaned in his home. The woman, who spoke on the condition of anonymity because of her sense of shame and her fears of deportation, said he raped her, took pictures of her naked, and threatened to put them on social media if she tried to go to the police. He then stalked her, she said.

Noemi Sanchez, Long Island regional coordinator for the Rural & Migrant Ministry, a nonprofit that supports farm workers, is working closely with the woman to elevate her self-esteem and help her understand that “no woman deserves to have a man mistreat them.”

Meanwhile, the survivor from India received a temporary work permit in 2024 and is employed as a certified nursing assistant, which “helps me survive,” she said.

“I have really come a long way,” she added. “It wasn’t easy. I had great support behind me. They didn’t let me down.”

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If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

Elliott Hinkle experienced depression and suicidal thoughts even before entering the foster care system in Casper, Wyoming, at age 15.

At the time, Hinkle, who is transgender, struggled with their sexual identity and gender issues, and their difficulties continued in foster care. They felt like they had no one to confide in — not their foster parents, not church leaders, not their caseworker.

“To my knowledge, I don’t remember ever taking a suicide screening,” Hinkle said. “No one ever said: ‘Are you having thoughts of taking your life? Do you feel hopeless?’”

With their psychological and behavioral health needs left unaddressed, Hinkle’s depression and suicidal thoughts worsened.

“Do I stay in the closet and feel terrible and want to end my life?” Hinkle said. “Or do I come out and lose all my supports, which also feels dangerous?”

Children in foster care are significantly more likely to have mental health issues, researchers say. They attempt or complete suicide at rates three to four times that of youths in the general population, according to .

LGBTQ+ people in foster care, like Hinkle, are at an even of having suicidal thoughts.

Yet despite the concentration of young people at risk of serious mental illness and suicide, proactive efforts to screen foster children and get them the treatment they need have been widely absent from the system. And now, efforts underway to provide widespread screening, diagnosis, and treatment are threatened by sweeping funding cuts the Trump administration is using to reshape health care programs nationwide.

In June, federal officials announced they would serving LGBTQ+ youths as part of those cuts.

Children in foster care use a disproportionate amount of Medicaid-funded mental health services. Meanwhile, President Donald Trump’s massive budget package, passed this month by Congress, contains substantial that are projected to drastically reduce services in many states.

“I think anybody who cares about kids’ well-being and mental health is concerned about the possibility of reduced Medicaid funding,” said Cynthia Ewell Foster, a child psychologist and clinical associate professor in the University of Michigan psychiatry department. “The most vulnerable children, including those in foster care, are already having trouble getting the services they need.”

A lack of federal standards and other system-level issues create barriers to psychological and behavioral care in the child welfare system, said Colleen Katz, a professor at Hunter College’s Silberman School of Social Work in New York.

“When you’re talking about anyone getting screened for suicide ideation upon entrance into the system, it’s inconsistent at best,” she said.

Katz said all children entering foster care should have a brief, standardized suicide screening embedded into their initial medical assessment. And more screenings need to be conducted throughout a foster care stay, she said, because youths getting ready to transition out of the system are also vulnerable. 

Hinkle, now 31, said the summer before they aged out of the system was “one of the darkest periods, because I was coming to terms with the church not wanting me to be gay and I was about to lose stable housing and whatever foster care support there was.”

Katz studied transition-age youths in foster care in California, which has the highest numbers of placements in foster care nationwide. According to , 42% of study participants had thoughts of taking their life and 24% had attempted suicide, and she expects findings would be similar in other states.

Katz also and found many that already exist could work and be easily administered by trained child welfare workers or alternative frontline service providers, or embedded in existing mental health services.

Still, the quality of services varies by state and locality and can hinder attempts to curb suicides.

Julie Collins, vice president of practice excellence at the Child Welfare League of America, which advocates for improvements to the child welfare system, said the gap in suicide prevention in foster care mirrors the overall nationwide void of behavioral health services for children and adolescents. “The preparation of people coming into the field isn’t what it needs to be,” Collins said of the lack of training for caseworkers.

Ewell Foster is trying to change that.

She worked with the state of Michigan to redefine and update the competencies required to earn an undergraduate certificate in child welfare in the state. Eighteen colleges and universities that offer certificate programs in child welfare in Michigan now teach about suicide prevention.

“It’s something the workforce has asked for,” Ewell Foster said. “They need real clear guidance on what to do when they are worried about someone.”

So far, Ewell Foster’s effort to change the wider system has not run into any roadblocks. Her work with Michigan’s child welfare agency is still being funded under a grant administered by the Substance Abuse and Mental Health Services Administration.

Agency spokesperson Danielle Bennett said such grants will continue for up to three years.

However, the future of the federal agency has been in question for months. The Trump administration has laid off hundreds of its employees and has proposed folding its functions into another agency.

Some states have made changes to address the foster care gaps on their own, but often it has taken legal action to spark changes in suicide prevention efforts.

In Kansas, officials made several changes after the state settled the McIntyre v. Howard class action lawsuit in 2021 on behalf of foster children who the suit alleged were subjected to inadequate access to mental health resources and moved from home to home frequently.

The state increased salaries for social workers in the child welfare system and reduced their caseloads, among other things.

Other states, including Texas, have implemented similar changes after facing lawsuits.

Still, experts caution that the changes taking place in foster care systems are not enough to steer outcomes.

Lily Brown, an assistant professor of psychology and director of the Center for the Treatment and Study of Anxiety at the University of Pennsylvania Perelman School of Medicine, said moving the needle in suicide prevention will require for children in state care.

Brown recently sought a grant to fund and implement free, universal suicide risk screening in foster care throughout Pennsylvania. She had several counties agree to the project, but not enough to support her application — the study wouldn’t have had enough participants to work statistically, she said.

Without such studies, foster care systems nationwide can’t meet the needs of children, she said.

April Miller, 27, entered the system in Minnesota at age 3. As a Native American, she is part of a group that is overrepresented in foster care.

“The child welfare system as a whole neglected me,” said Miller, who said she endured several traumatic events in her early life, including witnessing a murder.

“I did a lot of self-harm and had thoughts of suicide but didn’t have access to means, which is why I am still alive,” she said.

Today, Miller is a social worker and suicide prevention coordinator in Bemidji, Minnesota.

Similarly, Hinkle’s experience in the system made them driven to change the trajectory of other young people.

Hinkle provides training, consultation, and policy development services at Unicorn Solutions in Oregon in support of youths and young adults affected by systems such as child welfare, with a particular focus on the LGBTQ+ community.

They said they are committed to making sure that sexual identity and gender topics are not avoided in the system.

“I think every young person should feel loved and cared for,” Hinkle said.

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“It put a smile on my face to see him so happy,” Schachter said.

Alex would have turned 21 that day, six years after he and 16 other children and staff at Marjory Stoneman Douglas High School in Parkland, Florida, were shot and killed by a former student in 2018. In the years before the shooting, that former student had displayed concerning behavior that to 911 and at least two tips to the FBI.

“Alex should still be here today. It’s not fair,” Schachter said.

After two weeks of grieving Alex’s death, Schachter, propelled by anger and pain, began advocating for school safety. In part, he wanted to ensure his three other children would never be harmed in the same way. He joined the newly formed Marjory Stoneman Douglas High School Public Safety Commission to improve the safety and security of Florida’s students. And he launched a , which advocates for school safety.

Doing that work, he learned about threat assessment teams, groups of law enforcement and school officials who try to identify potentially dangerous or distressed kids, intervene, and prevent the next school shooting. Florida is one of that require schools to have threat assessment and intervention teams; a national survey estimates have a team assigned to the task.

The teams, whose mission and operational strategies often are based on research from the FBI and the Secret Service’s National Threat Assessment Center, or NTAC, have become more common as the number of school shootings has increased. Despite their prevalence for almost 25 years, some of the teams have developed systemic problems that put them at risk of unfairly labeling and vilifying children.

States vary widely in their requirements of threat assessment teams and there isn’t a nationwide archetype. Few school districts and states collect data about the teams, little is known about their operations, and research on their effectiveness at thwarting mass shootings and other threats is limited. But a by the NTAC of 67 plots against K-12 schools found that people “contemplating violence often exhibit observable behaviors, and when community members report these behaviors, the next tragedy can be averted.”

“School shooters have a long thought process. They don’t just snap. They have concerning behavior over time. If we can identify them early, we can intervene,” said Karie Gibson, chief of the FBI’s Behavioral Analysis Unit.

Yet, Dewey Cornell, a forensic clinical psychologist who in 2001 developed one of the first sets of guidelines for school threat assessment teams, said there have been problems. In many cases, he said, threats have been deemed not serious “but parents and teachers are so alarmed that it is difficult to assuage their fears. The school community gets in an uproar and the school administrators feel pressured to expel the student.”

And in other cases, a school doesn’t do a threat assessment and assumes a student is dangerous when somebody else reports them as a threat, and they may take a zero tolerance approach and remove them from the school, said Cornell, the Virgil S. Ward professor of education at the University of Virginia.

A task force convened by the found little evidence that zero tolerance policies have improved school climate or school safety and said they may create negative mental health outcomes for students. The task force cited examples of students who were expelled for incidents or school rule violations as minor as having a knife in their lunch box for cutting an apple.

Marisa Randazzo, a research psychologist and the director of threat assessment for Georgetown University, said she has also seen “hyperreactions,” especially among school communities that have experienced a mass killing.

“It’s understandable. People who have been close to an event like this are on higher alert than other people,” said Randazzo, who previously worked for the Secret Service and co-founded Sigma Threat Management Associates.

Threat assessments are supposed to be a graduated process calibrated to the seriousness of a problem, since the majority of student threats are not credible and can be resolved through supportive interventions, from the Secret Service.

Stephanie Crawford-Goetz, a school psychologist and the director of mental health for student support services in the Douglas County School District in Colorado, where a at a charter school in 2019, said her district’s threat assessment process emphasizes a proactive, rehabilitative approach to managing potential threats, as the NTAC suggests.

Crawford-Goetz said her district interviews students before convening the team to assess whether a threat is a misguided expression of anger or frustration and if the student has a plan and means to carry out violence.

Students whose threats are deemed transient receive support, such as help with coping skills, and they may meet with a mental health provider.

If the threat is credible, a student may be temporarily removed from the classroom or school.

Randazzo said the vast majority of kids who make threats are suicidal or despondent: “The process is designed primarily to figure out if someone is in crisis and how we can help. It is not designed to be punitive.”

Crawford-Goetz tells parents about her district’s threat assessment team at the beginning of the school year. Some districts report keeping their teams a secret from parents, which is not how they were designed to operate, said Lina Alathari, chief of the NTAC. Her team encourages schools to educate the whole community about the threat assessment process.

Some advocacy groups contend that threat assessment teams have perpetuated inequities. There has also been widespread concern that children with disabilities can easily get swept into a threat assessment.

In a 2022 report, the National Disability Rights Network, a nonprofit based in Washington, D.C., said some threat assessment teams have become “,” going beyond assessing risk of serious, imminent harm to determining guilt and punishment.

Expanding their scope allows threat assessment teams to get around civil rights protections, the report says.

Cornell disputed the disability rights group’s conclusion. “This has not been corroborated by scientific studies and is speculative,” he said.

Some states, such as Florida, mandate that threat assessment teams determine whether a student’s disability played a role in their behavior and recommend they include special education teachers and other professionals in their evaluation.

In Texas, which has mandated threat assessment teams, a third of students subjected to threat assessments in the Dallas Independent School District receive special education services.

Yet, the district a special education staff representative on its threat assessment team, according to a March 2023 report by Texas Appleseed, a nonprofit public interest justice center.

Many school districts are developing their own models in the absence of national standards for threat assessments.

Florida revamped its threat assessment system in January 2024 to improve response times, provide consistent data collection, and build in more checks and balances and oversight, said Pinellas County Sheriff Bob Gualtieri, who is also chair of the Marjory Stoneman Douglas High School Public Safety Commission.

The new model requires the teams to work quickly and file uniform, electronic summary reports of threat assessment findings. Those results follow students throughout their school years.

The adjustments are intended to eliminate the risk of not knowing about a student’s past troubling behavior if they change schools, as occurred with the Parkland shooter and a student who shot and killed classmates at a high school near Winder, Georgia, in September, said Gualtieri.

“As parents, you never stop worrying about your kids,” Schachter said.

Virginia mandates that all public schools and higher education institutions, including colleges, have threat assessment teams. In Florida, where one of Schachter’s daughters attends college, threat assessment teams are mandated in all public schools, including charter schools.

“There’s more work to be done,” Schachter said.

Cheryl Platzman Weinstock’s reporting is supported by a grant from the National Institute for Health Care Management Foundation.

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If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

When Pooja Mehta’s younger brother, Raj, died by suicide at 19 in March 2020, she felt “blindsided.”

Raj’s last text message was to his college lab partner about how to divide homework questions.

“You don’t say you’re going to take questions 1 through 15 if you’re planning to be dead one hour later,” said Mehta, 29, a mental health and suicide prevention advocate in Arlington, Virginia. She had been trained in — a nationwide program that teaches how to identify, understand, and respond to signs of mental illness — yet she said her brother showed no signs of trouble.

Mehta said some people blamed her for Raj’s death because the two were living together during the covid-19 pandemic while Raj was attending classes online. Others said her training should have helped her recognize he was struggling.

But, Mehta said, “we act like we know everything there is to know about suicide prevention. We’ve done a really good job at developing solutions for a part of the problem, but we really don’t know enough.”

Raj’s death came in the midst of decades of unsuccessful attempts to tamp down suicide rates nationwide.

During the past two decades federal officials have launched three national suicide prevention strategies, including one announced in April.

The first strategy, announced in 2001, focused on addressing risk factors for suicide and leaned on a few common interventions.

The next strategy called for developing and implementing standardized protocols to identify and treat people at risk for suicide with follow-up care and the support needed to continue treatment.

The latest strategy builds on previous ones and includes a federal action plan calling for implementation of 200 measures over the next three years, including prioritizing populations disproportionately affected by suicide, such as Black youth and Native Americans and Alaska Natives.

Despite those evolving strategies, from 2001 through 2021 suicide rates , according to the Centers for Disease Control and Prevention. , the most recent numbers available, shows deaths by suicide grew an additional 3% over the previous year. CDC officials project the final number of suicides in 2022 will be higher.

In the past two decades, suicide rates in such as Alaska, Montana, North Dakota, and Wyoming those in urban areas, according to the CDC.

Despite those persistently disappointing numbers, mental health experts contend the national strategies aren’t the problem. Instead, they argue, the policies — for many reasons —simply aren’t being funded, adopted, and used. That slow uptake was compounded by the covid-19 pandemic, which had a broad, negative impact on mental health.

A chorus of national experts and government officials agree the strategies simply haven’t been embraced widely, but said even basic tracking of deaths by suicide isn’t universal.

Surveillance data is commonly used to drive health care quality improvement and has been helpful in addressing cancer and heart disease. Yet, it hasn’t been used in the study of behavioral health issues such as suicide, said Michael Schoenbaum, a senior adviser for mental health services, epidemiology, and economics at the National Institute of Mental Health.

“We think about treating behavioral health problems just differently than we think about physical health problems,” Schoenbaum said.

Without accurate statistics, researchers can’t figure out who dies most often by suicide, what prevention strategies are working, and where prevention money is needed most.

Many states and territories don’t allow medical records to be linked to death certificates, Schoenbaum said, but with a handful of other organizations to document this data for the first time in a public report and database due out by the end of the year.

Further hobbling the strategies is the fact that federal and local funding ebbs and flows and some suicide prevention efforts don’t work in some states and localities because of the challenging geography, said Jane Pearson, special adviser on suicide research to the NIMH director.

Wyoming, where a few hundred thousand residents are spread across sprawling, rugged landscape, consistently ranks among the states with the highest suicide rates.

State officials have worked for many years to address the state’s suicide problem, said Kim Deti, a spokesperson for the Wyoming Department of Health.

But deploying services, like mobile crisis units, a core element of the latest national strategy, is difficult in a big, sparsely populated state.

“The work is not stopping but some strategies that make sense in some geographic areas of the country may not make sense for a state with our characteristics,” she said.

Lack of implementation isn’t only a state and local government problem. Despite evidence that screening patients for suicidal thoughts during medical visits , health professionals are not mandated to do so.

Many doctors find suicide screening daunting because they have limited time and insufficient training and because they aren’t comfortable discussing suicide, said Janet Lee, an adolescent medicine specialist and associate professor of pediatrics at the Lewis Katz School of Medicine at Temple University.

“I think it is really scary and kind of astounding to think if something is a matter of life and death how somebody can’t ask about it,” she said.

The use of other measures has also been inconsistent. Crisis intervention services are core to the national strategies, yet many states haven’t built standardized systems.

Besides being fragmented, crisis systems, such as mobile crisis units, can vary from state to state and county to county. Some mobile crisis units use telehealth, some operate 24 hours a day and others 9 to 5, and some use local law enforcement for responses instead of mental health workers.

Similarly, the fledgling 988 Suicide & Crisis Lifeline faces similar, serious problems.

Only 23% of Americans are familiar with 988 and there’s a significant knowledge gap about the situations people should call 988 for, according to a conducted by the National Alliance on Mental Illness and Ipsos.

Most states, territories, and tribes have also not yet permanently funded 988, which was launched nationwide in July 2022 and about $1.5 billion in federal funding, according to the Substance Abuse and Mental Health Services Administration.

Anita Everett, director of the Center for Mental Health Services within SAMHSA, said her agency is running an awareness campaign to promote the system.

Some states, including Colorado, are taking other steps. There, state officials installed financial incentives for implementing suicide prevention efforts, among other patient safety measures, through the state’s Hospital Quality Incentive Payment Program. The program hands out about $150 million a year to hospitals for good performance. In the last year, 66 hospitals improved their care for patients experiencing suicidality, according to Lena Heilmann, director of the Office of Suicide Prevention at the Colorado Department of Public Health and Environment.

Experts hope other states will follow Colorado’s lead.

And despite the slow movement, Mehta sees bright spots in the latest strategy and action plan.

Although it is too late to save Raj, “addressing the social drivers of mental health and suicide and investing in spaces for people to go to get help well before a crisis gives me hope,” Mehta said.

Cheryl Platzman Weinstock’s reporting is supported by a grant from the National Institute for Health Care Management Foundation.

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BRIDGEPORT, Conn. — Milagros Aquino was trying to find a new place to live and had been struggling to get used to new foods after she moved to Bridgeport from Peru with her husband and young son in 2023.

When Aquino, now 31, got pregnant in May 2023, “instantly everything got so much worse than before,” she said. “I was so sad and lying in bed all day. I was really lost and just surviving.”

Aquino has lots of company.

Perinatal depression affects as many as 20% of women in the United States during pregnancy, the postpartum period, or both, . In some states, anxiety or depression afflicts nearly a quarter of new mothers or pregnant women.

Many women in the U.S. go untreated because there is no widely deployed system to screen for mental illness in mothers, despite widespread recommendations to do so. Experts say the lack of screening has driven higher rates of mental illness, suicide, and drug overdoses that are now the leading causes of death in the first year after a woman gives birth.

“This is a systemic issue, a medical issue, and a human rights issue,” said Lindsay R. Standeven, a perinatal psychiatrist and the clinical and education director of the Johns Hopkins Reproductive Mental Health Center.

Standeven said the root causes of the problem include racial and socioeconomic disparities in maternal care and a lack of support systems for new mothers. She also pointed a finger at a shortage of mental health professionals, insufficient maternal mental health training for providers, and insufficient reimbursement for mental health services. Finally, Standeven said, the problem is exacerbated by the absence of national maternity leave policies, and the access to weapons.

Those factors helped drive a in postpartum depression from 2010 to 2021, according to the American Journal of Obstetrics & Gynecology.

For Aquino, it wasn’t until the last weeks of her pregnancy, when she signed up for acupuncture to relieve her stress, that a social worker helped her get care through the Emme Coalition, which connects girls and women with financial help, mental health counseling services, and other resources.

Mothers diagnosed with perinatal depression or anxiety during or after pregnancy are at about three times the risk of suicidal behavior and six times the risk of suicide compared with mothers without a mood disorder, according to recent U.S. and international studies in and .

The toll of the maternal mental health crisis is particularly acute in rural communities that have become maternity care deserts, as small hospitals close their labor and delivery units because of plummeting birth rates, or because of financial or staffing issues.

This week, the Maternal Mental Health Task Force — co-led by the Office on Women’s Health and the Substance Abuse and Mental Health Services Administration and formed in September to respond to the problem — that could serve as hubs of integrated care and birthing facilities by building upon the services and personnel already in communities.

The task force will soon determine what portions of the plan will require congressional action and funding to implement and what will be “low-hanging fruit,” said Joy Burkhard, a member of the task force and the executive director of the nonprofit Policy Center for Maternal Mental Health.

Burkhard said equitable access to care is essential. The task force recommended that federal officials identify areas where maternity centers should be placed based on data identifying the underserved. “Rural America,” she said, “is first and foremost.”

There are shortages of care in “unlikely areas,” including Los Angeles County, where some maternity wards have recently closed, said Burkhard. Urban areas that are underserved would also be eligible to get the new centers.

“All that mothers are asking for is maternity care that makes sense. Right now, none of that exists,” she said.

Several pilot programs are designed to help struggling mothers by training and equipping midwives and doulas, people who provide guidance and support to the mothers of newborns.

In Montana, rates of maternal depression before, during, and after pregnancy are higher than the national average. From 2017 to 2020, approximately 15% of mothers experienced postpartum depression and 27% experienced perinatal depression, according to the The state had the sixth-highest maternal mortality rate in the country in 2019, when it received a federal grant to begin training doulas.

To date, the program has trained 108 doulas, many of whom are Native American. Native Americans make up . Indigenous people, particularly those in rural areas, have of severe maternal morbidity and mortality compared with white women, according to a study in Obstetrics and Gynecology.

Stephanie Fitch, grant manager at Montana Obstetrics & Maternal Support at Billings Clinic, said training doulas “has the potential to counter systemic barriers that disproportionately impact our tribal communities and improve overall community health.”

and Washington, D.C., have Medicaid coverage for doula care, according to the National Health Law Program. They are California, Florida, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, Oklahoma, Oregon, Rhode Island, and Virginia. Medicaid pays for about in the U.S., according to the Centers for Disease Control and Prevention.

Jacqueline Carrizo, a doula assigned to Aquino through the Emme Coalition, played an important role in Aquino’s recovery. Aquino said she couldn’t have imagined going through such a “dark time alone.” With Carrizo’s support, “I could make it,” she said.

Genetic and environmental factors, or a past mental health disorder, can increase the risk of depression or anxiety during pregnancy. But mood disorders can happen to anyone.

Teresa Martinez, 30, of Price, Utah, had struggled with anxiety and infertility for years before she conceived her first child. The joy and relief of giving birth to her son in 2012 were short-lived.

Without warning, “a dark cloud came over me,” she said.

Martinez was afraid to tell her husband. “As a woman, you feel so much pressure and you don’t want that stigma of not being a good mom,” she said.

In recent years, programs around the country have started to help doctors recognize mothers’ mood disorders and learn how to help them before any harm is done.

One of the most successful is the Massachusetts Child Psychiatry Access Program for Moms, which began a decade ago and has since spread to 29 states. The program, supported by federal and state funding, provides tools and training for physicians and other providers to screen and identify disorders, triage patients, and offer treatment options.

But the expansion of maternal mental health programs is taking place amid sparse resources in much of rural America. Many programs across the country have run out of money.

The federal task force proposed that Congress fund and create consultation programs similar to the one in Massachusetts, but not to replace the ones already in place, said Burkhard.

In April, Missouri became the latest state to adopt the Massachusetts model. Women on Medicaid in Missouri are 10 times as likely to die within one year of pregnancy as those with private insurance. From 2018 through 2020, an average of 70 Missouri women died each year while pregnant or within one year of giving birth, according to state .

Wendy Ell, executive director of the Maternal Health Access Project in Missouri, called her service a “lifesaving resource” that is free and easy to access for any health care provider in the state who sees patients in the perinatal period.

About 50 health care providers have signed up for Ell’s program since it began. Within 30 minutes of a request, the providers can consult over the phone with one of three perinatal psychiatrists. But while the doctors can get help from the psychiatrists, mental health resources for patients are not as readily available.

The task force called for federal funding to train more mental health providers and place them in high-need areas like Missouri. The task force also recommended training and certifying a more diverse workforce of community mental health workers, patient navigators, doulas, and peer support specialists in areas where they are most needed.

A new in reproductive psychiatry is designed to help psychiatry residents, fellows, and mental health practitioners who may have little or no training or education about the management of psychiatric illness in the perinatal period. A small that the curriculum significantly improved psychiatrists’ ability to treat perinatal women with mental illness, said Standeven, who contributed to the training program and is one of the study’s authors.

Nancy Byatt, a perinatal psychiatrist at the University of Massachusetts Chan School of Medicine who led the launch of the Massachusetts Child Psychiatry Access Program for Moms in 2014, said there is still a lot of work to do.

“I think that the most important thing is that we have made a lot of progress and, in that sense, I am kind of hopeful,” Byatt said.

Cheryl Platzman Weinstock’s reporting is supported by a grant from the National Institute for Health Care Management Foundation.

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Amanda MorningStar has watched her children struggle with mental health issues, including suicidal thoughts. She often wonders why.

“We’re family-oriented and we do stuff together. I had healthy pregnancies. We’re very protective of our kids,” said MorningStar, who lives in Heart Butte, Montana, a town of about 600 residents on the Blackfeet Indian Reservation.

Yet despite her best efforts, MorningStar said, her family faces a grim reality that touches Native American communities nationwide. About a year ago, her 15-year-old son, Ben, was so grief-stricken over his cousin’s suicide and two classmates’ suicides that he tried to kill himself.

“Their deaths made me feel like part of me was not here. I was gone. I was lost,” said Ben MorningStar.

He spent more than a week in an inpatient mental health unit, but once home, he was offered sparse mental health resources.

Non-Hispanic Indigenous people in the United States than any other racial or ethnic group, according to the Centers for Disease Control and Prevention. The suicide rate among Montana’s Native American youth is more than five times the statewide rate for the same age group, according to the . Montana ranked among states for suicide deaths in 2020, and 10% of all suicides in the state from 2017 through 2021 were among Native Americans, even though they represent only 6.5% of the state’s population.

Despite decades of research into suicide prevention, suicide rates among Indigenous people have , especially among Indigenous people ages 10 to 24, according to the CDC. Experts say that’s because the national strategy for suicide prevention isn’t culturally relevant or sensitive to Native American communities’ unique values.

Suicide rates have increased among other , too, but to lesser degrees.

Systemic issues and structural inequities, including underfunded and under-resourced services from the federal Indian Health Service, also hamper suicide prevention in Indigenous communities. “I worried who was going to keep my son safe. Who could he call or reach out to? There are really no resources in Heart Butte,” said Amanda MorningStar.

Ben MorningStar said he is doing better. He now knows not to isolate himself when problems occur and that “it is OK to cry, and I got friends I can go to when I have a bad day. Friends are better than anything,” he said.

His twice-a-month, 15-minute virtual telehealth behavioral therapy visits from IHS were recently reduced to once a month.

Mary Cwik, a psychologist and senior scientist at the Center for Indigenous Health at Johns Hopkins Bloomberg School of Public Health in Baltimore, said the systemic shortcomings MorningStar has witnessed are symptoms of a national strategy that isn’t compatible with Indigenous value systems.

“It is not clear that the creation of the national strategy had Indigenous voices informing the priorities,” Cwik said.

The cause of high suicide rates in Indigenous communities is complex. Native Americans often live with the weight of more than other populations — things such as emotional, physical, and sexual abuse, intimate partner violence, substance misuse, mental illness, parental separation or divorce, incarceration, and poverty.

Those adverse experiences stack upon caused by racial discrimination, colonization, forced relocation, and government-sanctioned abduction to boarding schools that persisted until the 1970s.

“There’s no way that communities shaped by these forces for so long will get rid of their problems fast by medical services. A lot of people in Indian Country struggle to retain hope. It’s easy to conclude that nothing can fix it,” said Joseph P. Gone, a professor of anthropology and global health and social medicine at Harvard University and member of the Gros Ventre (Aaniiih) tribal nation of Montana.

Most tribal nations are interested in collaborative research, but funding for such work is hard to come by, said Gone. So is funding for additional programs and services.

Stephen O’Connor, who leads the suicide prevention research program at the Division of Services and Intervention Research at the National Institute of Mental Health, said, “Given the crisis of suicide in Native American populations, we need more funding and continued sustained funding for research in this area.”

Getting grants for scientific research from NIMH, which is part of the National Institutes of Health, can be challenging, especially for smaller tribes, he said.

Officials at the NIMH and the Substance Abuse and Mental Health Services Administration said that they continue to build research partnerships with tribal nations and that they recently launched new grants and multiple programs that are culturally informed and evidence-based to reduce suicide in tribal communities.

NIMH researchers are even adjusting a commonly used suicide screening tool to incorporate more culturally appropriate language for Indigenous people.

Teresa Brockie, an associate professor at Johns Hopkins School of Nursing, is one of a small but growing number of researchers, many of whom are Indigenous, who study suicide prevention and intervention strategies that respect Indigenous beliefs and customs. Those strategies include smudging — the practice of burning medicinal plants to cleanse and connect people with their creator.

Without this understanding, research is hampered because people in tribal communities have “universal mistrust of health care and other colonized systems that have not been helpful to our people or proven to be supportive,” said Brockie, a member of Fort Belknap reservation’s Aaniiih Tribe.

Brockie is leading studying Indigenous people at Fort Peck. The project aims to reduce suicide risk by helping parents and caregivers deal with their own stress and trauma and develop positive coping skills. It’s also working to strengthen children’s tribal identity, connectivity, and spirituality.

In 2015, she reported on a study she led in 2011 to collect suicide data at the Fort Peck reservation in northeastern Montana. She found that adverse childhood experiences on suicide risk and also that tribal identity, strong connections with friends and family, and staying in school were protective against suicide.

In Arizona, Cwik is collaborating with the White Mountain Apache Tribe to help leaders there evaluate the impact of a comprehensive suicide surveillance system they created. So far, the program has by 38.3 % and the rate among young people ages 15 to 24 by 23%, according to the American Public Health Association.

Several tribal communities are attempting to implement a similar system in their communities, said Cwik.

Still, many tribal communities rely on limited mental health resources available through the Indian Health Service. One person at IHS is tasked with addressing suicide across almost 600 tribal nations.

Pamela End of Horn, a social worker and national suicide prevention consultant at IHS, said the Department of Veterans Affairs “has a suicide coordinator in every medical center across the U.S., plus case managers, and they have an entire office dedicated to suicide prevention. In Indian Health Service it is just me and that’s it.”

End of Horn, a member of the Oglala Lakota Sioux Tribe of the Pine Ridge Indian Reservation in South Dakota, blames politics for the discrepancy.

“Tribal leaders are pushing for more suicide prevention programs but lack political investment. The VA has strong proactive activities related to suicide and the backing of political leaders and veterans’ groups,” she said.

It is also hard to get mental health professionals to work on remote reservations, while VA centers tend to be in larger cities.

Even if more mental health services were available, they can be stigmatizing, re-traumatizing, and culturally incongruent for Indigenous people.

Many states are using creative strategies to stop suicide. A pilot project by the Rural Behavioral Health Institute screened more than 1,000 students in 10 Montana schools from 2020 to 2022. The governor of Montana is hoping to use state money to expand mental health screening for all schools.

Experts say the kinds of strategies best suited to prevent suicide among Native Americans should deliver services that reflect their diversity, traditions, and cultural and language needs.

That’s what Robert Coberly, 44, was searching for when he needed help.

Coberly began having suicidal thoughts at 10 years old.

“I was scared to live and scared to die. I just didn’t care,” said Coberly, who is a member of the Tulalip Tribes.

He suffered in private for nearly a decade until he almost died in a car crash while driving drunk. After a stay at a rehabilitation center, Coberly remained stable. Years later, though, his suicidal thoughts came rushing back when one of his children died. He sought treatment at a behavioral health center where some of the therapists were Indigenous. They blended Western methodologies with Indigenous customs, which, he said, “I was craving and what I needed.”

Part of his therapy included going to a sweat lodge for ritual steam baths as a means of purification and prayer.

Coberly was a counselor for the Native and Strong Lifeline, the first 988 crisis line for Indigenous people. He is now one of the crisis line tribal resource specialists connecting Indigenous people from Washington state with the resources they need.

“It’s about time we had this line. To be able to connect people with resources and listen to them is something I can’t explain except that I was in a situation where I wanted someone to hear me and talk to,” said Coberly.

Amanda MorningStar said she still worries about her son night and day, but he tries to reassure her.

“I go to sleep and wake up the next day to keep it going,” Ben MorningStar said. “I only get one chance. I might as well make the best of it.”

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Jason Lance thought Jan. 21, 2010, was a day like any other until the call came.

He had dropped off his 9-year-old son, Montana, at Stewart’s Creek Elementary School in The Colony, Texas, that morning.

“There were no problems at home. He was smart. He wore his heart on his sleeve and he talked and talked and talked,” said Lance. It was “the same old, same old normal day. There were kisses and goodbyes and he said, ‘I love you, Daddy.’”

A few hours later, school officials called to say Montana had died by suicide while locked in the nurse’s bathroom.

“I knew he had some issues going on in school, but I never seen it coming,” said Lance. His shock and grief were complicated by the realization that there may have been more signs his son was struggling.

As children across the country step back into school routines this fall, it is important to pay attention to their mental health as well as their academics. Suicide ranks as either the seventh- or eighth-leading cause of death among children ages 5 to 11, according to the Centers for Disease Control and Prevention and . And numbers show the rates among younger kids appear to have increased in the past decade, especially among Black males.

A growing body of research shows that “historically we thought that suicide is a problem of teens and adults, but younger children are expressing similar thoughts that may have been ignored before,” said Paul Lipkin, a pediatrician at the Kennedy Krieger Institute in Baltimore and a specialist in developmental disabilities such as autism.

This has many experts calling for lowering the screening age for suicide ideation in children and moving to develop more effective early suicide risk detection and targeted prevention strategies. The broad approach includes pediatricians, teachers, and parents working with children at a young age to build their resilience and identify and manage their stress.

Studies have found that about death and killing oneself from TV or other media, discussions with other children, or exposure to death from a family or community loss.

“Pediatric suicide wasn’t on our radar decades ago and maybe was underreported,” said Holly Wilcox, president of the International Academy of Suicide Research and a professor at the Johns Hopkins Bloomberg School of Public Health in Baltimore. “The truth is that now we can do stuff about it.”

It is quite likely the 136 reported suicides from 2001 to 2021 among 5- to 9-year-olds were an undercount.

“Counts are often incomplete, and causes of death may be pending investigation resulting in an underestimate relative to final counts,” said Margaret Warner, a senior epidemiologist at the CDC.

The problems with those numbers are important because, Warner said, “if we are missing deaths, or don’t have all the information leading to them, we can’t properly develop programs to prevent future deaths.”

That’s why there’s also an ongoing national effort by coroners and medical examiners to improve the quality and consistency of pediatric death investigations.

Leaders in suicide prevention hope this wide spotlight on pediatric suicide will also help curtail the rising suicide rate among people ages 10 to 24 in the U.S. since suicide is the of death in that age group, according to the CDC.

Some of the increase in mental health issues among children has been attributed to the isolation and lack of school structure during the pandemic. Beginning in April 2020, pediatric emergency room visits for children 5 to 11 increased approximately 24%, according to a from November 2020.

Other factors, such as being neurodivergent or having a psychiatric disorder, can make a child more vulnerable to suicide.

A study published in also found that being the victim or perpetrator of bullying is a risk factor for suicide, even when researchers controlled for other risk factors.

Montana Lance was diagnosed with attention-deficit/hyperactivity disorder, as well as dyslexia, and often was the target of bullying at school.

Officials at the Lewisville Independent School District declined to comment on Montana’s death. His parents filed a lawsuit against the school district, but it was dismissed, and the district was found not liable for his death.

Suicide is complex, but recent studies have found that there are things parents, teachers, pediatricians, and caregivers can do to help protect children from it.

Lisa Horowitz, a pediatric psychologist and staff scientist at the National Institute of Mental Health, said, “It’s never too early to start a conversation with kids about recognizing mental health distress and doing what we can do to help them have better coping strategies and foster resilience.”

in children can help buffer them in times of stress, according to a study published in 2022 in Frontiers of Psychiatry.

“I don’t want people to panic but just want them to be vigilant about their children,” said Horowitz.

Sometimes that vigilance can be “tricky” because depression may look different in younger kids. They may act out, be more irritable, and not manifest their symptoms in the same way as teens and adults, Wilcox said.

“We don’t have enough studies on how best to identify preteens and children at risk for suicide. Oftentimes you just have to trust your gut about these things,” she said.

If a child is upset, parents should ask them questions about what they’re experiencing, said Tami D. Benton, psychiatrist-in-chief, executive director, and chair of the Department of Child and Adolescent Psychiatry and Behavioral Sciences at Children’s Hospital of Philadelphia.

“Parents shouldn’t talk kids out of their feelings or give them examples of when it happened to them, or minimize their feelings. It puts them down,” she said.

Parents and children should come up with a plan together, but also teach their children that they can master these situations, said Benton.

When parents get stuck about what to do in difficult situations, they should consult with their child’s pediatrician.

In March, the American Academy of Pediatrics recommended universal screening for suicide risk in all children 12 and older and when clinically indicated for kids 8 to 11. There aren’t any screening tools validated for use in children under 8. But Horowitz said younger children can still be assessed and evaluated for suicide risk.

Schools can also play an important role in suicide prevention.

Meghan Feby, a school counselor in the Colonial School District in New Castle, Delaware, said, “I am the sole school counselor in my building. It is a daunting task. That’s why there are supports in place that have eyes where I can’t have eyes … on school computers. Employing software strategies like GoGuardian Beacon can really help fill in gaps and supports.”

The software captures keywords and phrases that might indicate a child is thinking about suicide and has already been used to intervene when children using district computers displayed concerning behavior. It is monitoring activities on school computers used by more than 6.7 million public school students in kindergarten through 12th grade.

Some schools said they are having problems implementing software like this because some parents find it intrusive.

Many schools use the Good Behavior Game, a decades-old behavior management intervention for kids in first and second grades, and it has been used in higher grades. The team-oriented classroom curriculum uses peer pressure to stimulate students to be attentive and engaged and work together. Researchers such as Wilcox have studied the extensive participation of thousands of students and found it reduced suicidal thoughts and behaviors.

Children who have played the game as young adults to report suicidal thoughts and about a third less likely to report a suicide attempt.

Lance said that the day Montana died by suicide changed his life forever.

“You’re not supposed to bury your children. They’re supposed to bury you,” he said. “All this attention on the mental health status of children these days is not going to bring my child back, but it can stop another family from suffering.”

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If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”

Aimee Quicke has made repeated trips to emergency rooms, hospitals, behavioral health facilities, and psychiatric lockdowns for mental health crises — including suicidal thoughts — since she was 11.

The 40-year-old resident of Le Mars, Iowa, has bipolar and obsessive-compulsive disorders. “Some of the visits were helpful and some were not,” she said. “It was like coming in and going out and just nothing different was happening.”

Then she heard about Rhonda’s House, a rural peer respite program that opened on the other side of the state in 2018, through acquaintances in her community.

That facility, and dozens of others like it established nationwide over the past 20 years, offers a short-term, homelike, nurturing environment for people who are experiencing a mental health crisis but don’t need immediate medical attention. At respites, patients are treated like guests, proponents say, and can feel heard and keep their dignity without having to relinquish their clothes and other belongings.

During her weeklong stay at Rhonda’s House, which founder and executive director Todd Noack referred to as “a bed-and-breakfast facility for emotional distress,” Quicke made many breakthroughs, working on her self-esteem and gaining better coping skills. If she hadn’t found the program, she said, “I don’t think I would have come out of 2020.”

Public health professionals say respite facilities can potentially play a big role in addressing a national mental health crisis that accelerated dramatically during the covid-19 pandemic, especially when it comes to suicide prevention.

“It’s a really important piece of the larger puzzle of how to improve health care and reduce suicide risk, because there is a ‘traffic jam’ in suicide prevention,” said Jane Pearson, chair of the National Institute of Mental Health Suicide Research Consortium.

Respites rely on trained peers to provide care, and often serve patients who might otherwise visit overburdened ERs, psychiatric institutions, and therapists. Today there are 42 community-based respite programs spread across 14 states, including new ones opened recently in Tacoma, Washington, and Grand Rapids, Michigan. Most are nonprofits governed by a patchwork of state guidelines, and they’re funded by a mixture of local, state, and federal grants.

Experts say the programs fill a void, though there is little hard data on their effectiveness. Paolo del Vecchio, director of the Office of Recovery at the federal Substance Abuse and Mental Health Services Administration, said peer-run respites have proven themselves as an “evidence-based model of care,” with positive effects including reduced hospitalizations and increased engagement with community support services.

A 2015 study published online in the journal Psychiatric Services found that people who sought respite were to use inpatient emergency services than non-respite users.

Still, del Vecchio said, more research is needed to analyze how the programs are working and troubleshoot problems. SAMHSA is conducting a cost-benefit analysis of respite programs that officials hope to release this summer.

Pearson said she would like to see more research on who uses respites, how they are advertised, clients’ reasons for seeking them, and whether they deliver what they promise.

Respites can be especially important in rural America, where suicides increased 46% from 2000 to 2020, compared with 27.3% in urban areas, according to the Centers for Disease Control and Prevention. Rural residents also have 1½ times the rates of ER visits for self-harm as urban residents.

Del Vecchio hopes greater awareness can help bring the promising respite approach to the states with the highest suicide rates, including Wyoming, Montana, Alaska, and New Mexico.

Rhonda’s House, in Dewitt, Iowa, has provided care to 392 people over the past five years, and recently moved into a three-story, five-bedroom house with two baths. Peer specialists in Iowa must complete 40 hours of training plus six hours of ethics counseling, and then work 500 hours to become eligible to take a state certification test.

For Quicke, Rhonda’s House was a lifesaver during a brutal 2020. The pandemic had isolated her from her support system, her brother-in-law died, her long-term partner moved out, and her mother had open-heart surgery.

“There was a lot of chaos. A lot of family fights broke out. That’s when I took off — packed a bag and left for respite,” said Quicke. “There was nowhere else closer to go.”

She drove six hours from her home to Rhonda’s House, where she found 24-hour help that you “just can’t get from an emergency room or hospital.”

Unlike traditional hospital staffers, peers are available to speak with guests whenever they are needed, which Quicke appreciated since she has “a lot of panic and anxiety in the night and it’s frightful.” She also found it easy and comforting to speak with peers with “lived experience,” or firsthand experience with mental health challenges.

Allowing people to reach out for help without being judged is a crucial feature of the respite model, said Paul Pfeiffer, a psychiatrist at the University of Michigan’s medical center. He cautioned against regulations that would make them more like hospitals, noting that many people in trouble avoid getting help because they fear being locked up in a psychiatric facility.

Quicke said she learned a lot during her stay at Rhonda’s House. “I always thought I was co-dependent. I learned I just need me and my dogs. I learned wellness tools and that I can be strong and resourceful and resilient,” she said. She described being more conscious of her triggers and said she had “more routines to help with sleep hygiene.”

When Quicke left, respite staffers connected her with community resources close to her home, near the Nebraska border. They also encouraged her to call if she needed help again and told her she could return for another stay after 60 days — giving her time to work through her challenges and freeing up space for others in the meantime.

“Peer respite works 8 out of 10 times,” said Noack, the executive director. “Some people do have to leave to get another level of care, but nothing is ever perfect.”

The average cost of staying at Rhonda’s House is $428 a day — far less than the thousands of dollars a hospital stay typically costs. Noack’s respite does not bill insurance but covers the cost with state and regional contracts, as well as donations, like many other respites.

Some respites receive Medicaid funding. As this type of care grows, more states will explore Medicaid and other funding sources, said del Vecchio.

A few weeks ago Quicke became discouraged after a job rejection. She thought about going back to Rhonda’s House but said she channeled what she learned there during her stay.

“I was able to use my coping skills to get through it,” she said.

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“I had [acute] paranoia and depression off the roof,” said Marcell, 46, who asked to be identified only by his first name because he wanted to maintain confidentiality about some aspects of his illness.

Marcell’s depression was so profound, he said, he didn’t want to move and was considering suicide.

“Things were getting overwhelming and really rough. I wanted to end it,” he said.

Marcell, diagnosed with schizoaffective disorder seven years ago, had been this route before but never during a pandemic. The Detroit area was a coronavirus hot spot, slamming hospitals, attracting concerns from federal public health officials and recording more than 1,000 deaths in Wayne County as of May 28. Michigan ranks fourth among states for deaths from COVID-19.

The crisis enveloping the hospitals had a ripple effect on mental health programs and facilities. The emergency room was trying to get non-COVID patients out as soon as possible because the risk of infection in the hospital was high, said Jaime White, director of clinical development and crisis services for Hegira Health, a nonprofit group offering mental health and substance abuse treatment programs. But the options were limited.

Still, the number of people waiting for beds at Detroit’s crisis centers swelled. Twenty-three people in crisis had to instead be cared for in a hospital.

This situation was hardly unique. Although mental health services continued largely uninterrupted in areas with low levels of the coronavirus, behavioral health care workers in areas hit hard by COVID-19 were overburdened. Mobile crisis teams, residential programs and call centers, especially in pandemic hot spots, had to reduce or close services. Some programs were plagued by shortages of staff and protective supplies for workers.

At the same time, people battling mental health disorders became more stressed and anxious.

“For people with preexisting mental health conditions, their routines and ability to access support is super important. Whenever additional barriers are placed on them, it could be challenging and can contribute to an increase in symptoms,” said White.

After eight hours in the emergency room, Marcell was transferred to , a community outreach program for psychiatric emergencies for Wayne County Medicaid patients.

“We try to get patients like him into the lowest care possible with the least restrictive environment,” White said. “The quicker we could get him out, the better.”

Marcell was stabilized at COPE over the next three days, but his behavioral health care team couldn’t get him a bed in one of two local residential crisis centers operated by Hegira. Social distancing orders had reduced the beds from 20 to 14, so Marcell was discharged home with a series of scheduled services and assigned a service provider to check on him.

However, Marcell’s symptoms ― suicidal thoughts, depression, anxiety, auditory hallucinations, poor impulse control and judgment ― persisted. He was not able to meet face-to-face with his scheduled psychiatrist due to the pandemic and lack of telehealth access. So, he returned to COPE three days later. This time, the staff was able to find him a bed immediately at a Hegira residential treatment program, Boulevard Crisis Residential in Detroit.

Residents typically stay for six to eight days. Once they are stabilized, they are referred elsewhere for more treatment, if needed.

Marcell ended up staying for more than 30 days. “He got caught in the pandemic here along with a few other people,” said Sherron Powers, program manager. “It was a huge problem. There was nowhere for him to go.”

Marcell couldn’t live with his girlfriend anymore. Homeless shelters were closed and substance abuse programs had no available beds.

“The big problem here is that all crisis services are connected to each other. If any part of that system is disrupted you can’t divert a patient properly,” said Travis Atkinson, a behavioral consultant with TBD Solutions, which collaborated on a survey of providers with the American Association of Suicidology, the Crisis Residential Association and the National Association of Crisis Organization Directors.

White said the crisis took a big toll on her operations. She stopped her mobile crisis team on March 14 because, she said, “we wanted to make sure that we were keeping our staff safe and our community safe.”

Her staff assessed hospital patients, including Marcell, by telephone with the help of a social worker from the emergency room.

People like Marcell have struggled during the coronavirus crisis and continue to face hurdles because emergency preparedness measures didn’t provide enough training, funds or thought about the acute mental health issues that could develop during a pandemic and its aftermath, said experts.

“The system isn’t set up to accommodate that kind of demand,” said Dr. Brian Hepburn, a psychiatrist and executive director of the National Association of State Mental Health Program Directors.

“In Detroit and other hard-hit states, if you didn’t have enough protective equipment you can’t expect people to take a risk. People going to work can’t be thinking ‘I’m going to die,’” said Hepburn.

For Marcell, “it was bad timing to have a mental health crisis,” said White, the director at Hegira.

At one time Marcell, an African American man with a huge grin and a carefully trimmed goatee and mustache, had a family and a “pretty good job,” Marcell said. Then “it got rough.” He made some bad decisions and choices. He lost his job and got divorced. Then he began self-medicating with cocaine, marijuana and alcohol.

By the time he reached the residential center in Detroit on April 1, he was at a low point. “Schizoaffective disorder comes out more when you’re kicked out of the house and it increases depression,” said Powers, the program manager who along with White was authorized by Marcell to talk about his care. Marcell didn’t always take his medications and his use of illicit drugs magnified his hallucinations, she said.

While in the crisis center voluntarily, Marcell restarted his prescription medications and went to group and individual therapy. “It is a really good program,” he said while at the center in early May. “It’s been one of the best 30 days.”

Hepburn said the best mental health programs are flexible, which allows them more opportunities to respond to problems such as the pandemic. Not all programs would have been able to authorize such a long stay in residential care.

Marcell was finally discharged on May 8 to a substance abuse addiction program. “I felt good about having him do better and better. He had improved self-esteem to get the help he needed to get back to his regular life,” Powers said.

But Marcell left the addiction program after only four days.

“The [recovery] process is so individualized and, oftentimes, we only see them at one point in their journey. But, recovering from mental health and substance use disorders is possible. It can just be a winding and difficult path for some,” said White.

Seeking Help

If you or someone you know is in immediate danger, call 911. Below are other resources for those needing help:

— National Helpline: 1-800-662-HELP (4357) or .

— National Suicide Prevention Lifeline: 1-800-273-TALK (8255).

— Disaster Distress Helpline: 1-800-985-5990 or text TalkWithUs to 66746.

This <a target="_blank" href="/health-industry/in-hard-hit-areas-covids-ripple-effects-strain-mental-health-care-systems/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">