Five years ago, if a child younger than 13 arrived at Maine Medical Center for treatment following a suicide attempt, it was rare and notable.

It’s no longer rare.

“We’re seeing more of them and they’re younger. We have seen as young as 7 to 9 years old, which we never saw,” said Dr. Robyn Ostrander, division director of child and adolescent psychiatry. “It’s hard to wrap your head around that a child of that age would even conceive of suicide or know what it is, but it happens.”

In Maine and across the country, the number of adolescents who attempt suicide has risen dramatically, setting off alarm bells for mental health and suicide prevention experts who say more focus needs to be placed on talking about it and providing access to mental health services.

The increase is being driven largely by girls, who experts say experience depression at higher rates than boys and may be more likely to seek help for self-inflicted injuries.

Nationwide, emergency room visits following suicide attempts by girls age 12 to 17 spiked in 2020 and the first months of 2021. The number of girls who went to the hospital after a suspected suicide attempt rose 51 percent from March 2019 to March 2021, according to a recent analysis by the U.S. Centers for Disease Control and Prevention. The increase among boys was 3.7 percent.

Maine is experiencing the same upward trend in suicide attempts as shown in the national numbers, but the Maine CDC is still analyzing data from emergency departments and does not have final numbers, said Sheila Nelson, who oversees the Maine Suicide Prevention Program. She said Maine has continued to see an increase in suicide-related emergency department visits among youth – especially girls under the age of 18 – this summer, as compared with the same period in 2020 and 2019.

On average, there are 450 hospital discharges annually due to intentional self-inflicted injuries among Maine youth ages 10 to 24, according to the CDC.

While suicide attempts are on the rise, there has not been a corresponding increase in suicide deaths in Maine or nationally. This may be partly because the increase in attempts has been primarily among girls, who are more likely to self-report a suicide attempt, and because they tend to use less lethal means than boys.

“Right now, we have not seen an increase in suicide deaths among youth or adults since the beginning of the pandemic. That’s really good. But that analysis from the CDC is potentially a little bit of an alarm bell going off that we know young people are being affected and being affected pretty acutely,” Nelson said. “This (pandemic) has been a lot for them, especially for young people who may have already been struggling. It is challenging from an emotional and social perspective.”

The data about increases in suicide attempts comes as other recent surveys show teenagers and young adults are reporting that they feel more depressed and anxious since the beginning of the pandemic. But experts also caution that the research about suicide attempts among adolescents did not specifically look at whether the pandemic was a factor, and they note that the number of suicide attempts in Maine was already rising before the start of the pandemic.

Teens may be particularly at risk for suicide because they are especially affected by factors such as physical distancing, barriers to mental health treatment, substance use and anxiety about family health and economic problems, according to suicide prevention and health experts. They say the new data show the need for strong suicide prevention programs and more focus on mental health.

Starting in September, the Maine CDC will receive nearly $850,000 from the U.S. Centers for Disease Control and Prevention to support youth anti-suicide programs. The money will be used by state health officials to strengthen and expand prevention programs they say are essential to raise awareness about mental health, connect struggling adolescents to resources and prevent suicide.

“The timing is really critical. We’re going to need (that funding) more than ever in the next few months as we work toward recovering,” Nelson said. “The need was already there before COVID and we expect it will continue to be there for both young people and adults.”

Sens. Susan Collins and Angus King recently announced that the Maine Comprehensive Suicide Project was awarded funding by the U.S. CDC’s National Center for Injury Prevention and Control to support youth suicide prevention programs in schools and clinical settings. The Maine Comprehensive Suicide Project is a collaborative initiative among several state agencies that aims to educate and train adults in specific suicide prevention strategies and skills before they teach about suicide prevention, especially to youth.

“Suicide is a leading cause of death among Maine youth, and this heartbreak has affected far too many families. The pandemic and its consequences, such as social isolation, have only exacerbated mental health issues,” the senators said in a joint statement. “This critical funding will help our state build and strengthen suicide prevention programs. We will continue to work to provide the resources needed to help prevent these tragedies.”

Nelson said that money will be distributed across several programs, including Zero Suicide, which focuses on training in clinical settings, and on Sources of Strength, a school-based program for youth and adults that is expanding at a critical time for Maine students. Youth advocates say it is essential to involve young people in conversations about mental health and how to prevent suicide.

“Young folks have needed help, need help now and will absolutely need help as things return to ‘normal,'” Nelson said. “We know that it’s a hard time for people. They think they should feel better, but they don’t actually feel better. That’s a tough place to be in.”

DEVASTATING TRENDS

After a decadelong decline in teen suicide rates nationwide, the trend reversed in 2007. The number of youth ages 10 to 17 who die by suicide has risen nearly every year since. Thirty percent of people who die by suicide had a history of suicide attempts.

Each year, approximately 30 youth in Maine die by suicide, making it the second leading cause of death for people between the ages of 10 and 24 after unintentional injury, according to the most recent data available from the Maine CDC. For every five youth suicides in Maine, four are male. Maine’s youth suicide rate in 2018 was 12.6 per 100,000, higher than the national rate of 9.1 suicides.

Nelson said girls are significantly more likely to consider suicide than boys. And girls are much more likely to visit an emergency department or be hospitalized for intentional self-inflicted injuries than boys, who are more likely to use firearms and less likely to survive.

Among Maine high school students, 15 percent seriously considered suicide and 7 percent attempted suicide in the past year, according to a 2017 analysis by the CDC. Among middle school students, 16 percent had seriously considered suicide and 6 percent had attempted suicide.

Ostrander said the most recent youth risk behavior survey from the CDC showed a significant increase in the levels of depression reported by teens. In 2019, more than 31 percent of students said they had felt sad and hopeless, up from 27 percent two years earlier. And more teens reported they had seriously considered suicide (15.8 percent), made a plan (13.1 percent) and attempted suicide (8.5 percent).

Ostrander said LGBTQ youth have “significantly worse” mental health outcomes, with more than 40 percent reporting they have considered suicide. In 2017, 36 percent of gay or lesbian and 43 percent of bisexual high school students reported suicidal thoughts in the past year, compared with 11 percent of their heterosexual peers, according to the CDC.

Among transgender students, 54 percent reported suicidal thoughts in the past year, compared with 14 percent of non-transgender students, according to the Maine CDC.

While suicide statistics tend to focus on people ages 12 and older, Ostrander said it’s becoming less rare to see younger children coming into the hospital after a suicide attempt.

Experts in other parts of the country also have sounded alarms about suicide attempts among younger kids, saying more attention needs to be paid to their mental health by health care providers and parents.

Across all ages, suicide rates are higher in rural areas of the country such as Maine, where suicide risks include poverty, stigma, more access to firearms, less access to mental health and medical services, and isolation, especially for LGBTQ and racial/ethnic minorities.

Other risk factors for suicide include previous suicide attempts, substance abuse, physical disability or illness, relationship problems, losing a loved one to suicide, bullying, mental health conditions, the recent death of a family member or close friend, and access to harmful means such as firearms.

Maine Medical Center is analyzing data on suicide attempts, but Ostrander said anecdotally that it is clear there are more youth coming in after suicide attempts who are admitted for medical treatment. She said it is too soon to say why this is happening or what impact the pandemic may have had on these increases. Other contributing factors may include increased firearm access, younger age of puberty, and easier, earlier access to alcohol and drugs.

“We definitely know that a lot of kids became completely unstructured in their lives during COVID. In-school education is maybe the biggest structuring element for a child and also gets them noticed by caring adults outside their own home,” Ostrander said. “It’s possible kids were doing very poorly and just no one knew because no one was laying eyes on them.”

With a higher demand for services to treat children, Maine Medical Center for the first time had to create a wait list for treatments such as psychotherapy. The increased need for services is coming at a time when some clinicians have left the workforce or cut back their hours to care for children during the pandemic, Ostrander said. The high cost of living, skyrocketing housing costs and a lack of loan reimbursement programs in Maine make it difficult to recruit behavioral health professionals to fill open jobs, Ostrander said.

Maine Medical Center and Maine Behavioral Health have implemented a new screening as part of the Zero Suicide initiative, which is designed to improve practices and policies that identify and support individuals at increased risk of suicide. At the Barbara Bush Children’s Hospital, the screening tool is used to ask every patient a series of questions about depression, anxiety and substance use.

Ostrander said clinicians are also having conversations with parents about preventing their children from getting access to lethal means, including firearms. That doesn’t necessarily mean that families can’t have guns, but they should be locked up instead of just hidden, she said.

“When a child uses a firearm to make a suicide attempt, it’s a complete tragedy and 100 percent preventable,” Ostrander said. “They should not have unsupervised access to firearms, but they do.”

COMBATING ISOLATION

Greg Marley, director of suicide prevention for NAMI Maine, said the sense of being cut off from the things that help address stress, anxiety and depression during the pandemic created a “perfect storm” for people struggling with mental health.

“The uncertainty, the isolation, the loss of direction in the future and hope has been really hard on young people, especially,” he said.

Just as the pandemic arrived in Maine and closed schools to in-person learning, the Maine Suicide Prevention Program and NAMI Maine were bringing a new program into schools that brings together adults and students to talk about mental health and prevent suicide. Sources of Strength uses teams of peer leaders mentored by adult advisors to change peer social norms about seeking help and encourages students to individually assess and develop strength in life.

After going through training, peer leaders and adult advisors start conversations and activities to engage other students in messages about hope, help and strength. The program also provides an opportunity to help teachers and staff see their role as connectors for students who may be struggling, in emotional distress or suicidal.

Sources of Strength has already been implemented in five middle and high schools in Maine, but will expand this fall. In the future, it will expand to the elementary level.

“As young people come back in, it’s going to be a challenging transition for everyone. We’re really trying to provide as much intentional support as we can and try to decrease stigma among young people around mental health and the need to take care of their mental health and to get support if they’re struggling,” Nelson said. “We want to normalize that we all have to take care of ourselves mentally and emotionally. For many teens, the hardest part about the last 18 months is the isolation.”

At Mountain Valley High School in Rumford, principal Matthew Gilbert is looking forward to a more normal school year to fully promote Sources of Strength, which launched there last year. The school was looking for ways to help with social and emotional learning and Sources of Strength seemed like a good next step after the school offered mental health first-aid training with NAMI Maine. That intensive daylong program helps allies understand mental health and learn basic skills to support someone who is struggling.

Last year, 20 Mountain Valley students participated in Sources of Strength training to help identify skills needed to be well-balanced in their own life and what to do if they are concerned about someone who is struggling. Those students come from different social groups, clubs and teams, which Gilbert hopes will help ensure that all students feel connected and don’t slip through the cracks if they are struggling with their mental well-being.

“This affects kids from every walk of life,” he said.

Involving students and educators in Sources of Strength to talk about mental health is more important than ever, Gilbert said.

“Since March of 2020, kids have been isolated more than ever before. That isolation is going to play a factor in their social and emotional health and development. That’s something we need to be concerned about,” he said. “Kids can feel really isolated and alone. When you have those feelings, sometimes you start to think it’s not normal. It’s really easy to slip down that hole and withdraw. These programs help keep that in the forefront.”

NAMI Maine is also combating isolation with a teen support text line, which launched in April 2020 for Mainers ages 13 to 24. The text line is staffed by young people ages 18 to 24 who are overseen by a clinician and can provide support and information about available resources.

“They can help someone realize they’re not alone,” said Marley, from NAMI Maine.

SMASHING THE STIGMA

Julia Hansen was a sophomore in high school, struggling with depression and with the loss of her two best friends to suicide within six months of each other. When her high school sent a letter days after one of the deaths about things being “back to normal” instead of creating space for people to talk about the loss, she knew something had to change.

“I was done losing loved ones to suicide,” she said. “I was done struggling silently with the stigma around the topic.”

Hansen, now a 21-year-old college student from Peaks Island, started the Yellow Tulip Project with her mother, Suzanne Fox. The core mission of the Portland-based nonprofit is to “smash the stigma” around talking about mental health and to build a community to remind people there is help and hope for those living with mental illness.

“Society hasn’t wanted to talk about mental illness. We see it as the elephant in the room that everyone knows is there but people don’t want to talk about,” Fox said. “We know that stigma keeps people from seeking the help they need.”

In the five years since the project launched, it has grown to include a network of hundreds of youth ambassadors in high schools across Maine and in other states who work to start productive conversations about how to face mental health challenges and combat rising rates of suicide. The Yellow Tulip Project also hosts a photo exhibit to change perceptions of what mental illness looks like, teaches storytelling to youth so they can share their own experiences, and encourages people to plant yellow tulips as a visual reminder that hope can bloom, Hansen said.

The project is now expanding to include programs about mental wellness for younger students after many teens shared that they started experiencing issues with mental health in elementary schools. Hansen is also encouraging schools to take easy proactive steps like putting magnets with crisis hotline numbers in school bathrooms where they are easily seen by struggling teens.

Conrad Gabriel, a 2020 Deering High School graduate who now attends Tulane University, was introduced to the Yellow Tulip Project in high school when a friend brought him to a tulip bulb planting event. He connected immediately with the project’s mission and helped bring ambassadors to his school and others across New England. He is now the director of public relations for the project and co-director of its youth leadership board.

One thing that’s become clear to Gabriel through his work with his peers and the Yellow Tulip Project is the power of youth speaking about their own challenges and the impact it has on other teens who no longer feel isolated and alone. But he also feels the youth voice needs to have a more central role in discussions about suicide and suicide prevention.

“Mental health organizations need to value the youth voice more than they already do,” Gabriel said. “I think it needs to be a discussion with youth and adults working together to talk about the best way to reduce these rates.”

Hansen said youth ambassadors have helped their peers “see and understand that they’re not alone and that there are resources and help out there.”

“It creates an outlet for people who are living silently or walking through the hallways quietly and sadly. It shows they’re not alone and someone cares to talk about it,” Hansen said. “They know someone else understands the struggle of mental health.”