CONTENT WARNING: This article references suicide. Please take caution when reading. If you need mental health support, call or text the national suicide and crisis lifeline — 988 — or consult our mental health resources page. 

By Rachel Crumpler

Rik Emaus came home one afternoon in August 2021 to find his teenage daughter distraught. 

“She just had this absolute look of loss and pain that I’ll never forget,” Emaus said, recalling how he found his daughter sitting on the couch holding a picture of her and three friends in their middle school prom dresses.

She had just found out that one of those friends in the photo had died by suicide.

It was the first of three teenage suicides to rock Transylvania County in three months that year. The cluster of suicides brought the simmering youth mental health crisis to the forefront in the small western North Carolina county of about 33,000 people.

People in the county didn’t initially know how to respond. Silence dominated, Emaus said, as people feared saying or doing the wrong thing. There wasn’t a local group to turn to on the issue; the county’s small health department didn’t have funding for a mental health coordinator.

Emaus, a retired physician, sprang into action after the third suicide. He knew someone had to step up to tackle the unfolding mental health crisis to save other lives in the community. So, in early 2022, he brought county stakeholders together to form TC Strong — a county coalition of youth, school and community leaders working together to improve youth mental health.

“We needed to come together as a community,” Emaus said. “We had to be all in — in trying to understand why the suicides were happening, digging deeper to understand the youth mental health crisis and engaging our youth themselves to be part of developing solutions.”

Transylvania isn’t the only county in the state where kids — and adults — are struggling with mental health issues and suicidality. It’s a statewide and national problem that has become a leading cause of death in the U.S. overall, and it now is the second leading cause of death for people ages 10 to 24.

In North Carolina, addressing the worsening mental health crisis has been the focus of a 12-month UNC Chapel Hill initiative called “Our State, Our Wellbeing.” The UNC Suicide Prevention Institute and Carolina Across 100 — a five-year university initiative looking to work in all of the state’s 100 counties — partnered with 15 teams from 24 counties across North Carolina to identify and implement strategies to improve mental health and decrease suicides.

The initiative’s organizers held a Statewide Summit on Suicide Prevention at UNC’s Friday Center on June 13, to discuss factors contributing to the mental health crisis and highlight work underway at the state and community level to curb suicide deaths. The summit drew 400 attendees from 61 of North Carolina’s counties.  

Decreasing the number of suicide deaths is an urgent matter, said Patrick Sullivan, director of the UNC Suicide Prevention Institute.

“This is something that’s killing people every day,” Sullivan said at the summit, noting that the rates are as high as he’s seen in his decades-long career. “We need to address this aggressively and urgently.” 

A worsening problem

Suicide is a growing issue in the United States; rates increased by 36 percent between 2000 and 2021, according to the Centers for Disease Control and Prevention. In 2021, 48,183 people died by suicide, amounting to about one death every 11 minutes. 

The number of suicides ticked even higher in 2022, reaching an all-time high of 49,476 deaths for a rate of 14.8 deaths per 100,000 people in the population. In 2010, the rate was 12.1 deaths per 100,000. 

In North Carolina, 1,412 people — including 104 youth ages 10 to 19 — died by suicide in 2021, according to the latest state data, a number that far outstrips the number of homicides (950) recorded for the same year. 

These numbers make suicide the second most common cause of death for children ages 10 to 14 and the third most common cause of death for people 15 to 34, according to the state health department. Thousands more North Carolinians showed up to emergency departments with suicidal thoughts or after attempting suicide.

Mental health experts say the worsening mental health crisis is driven by many factors, including isolation during the COVID pandemic, bullying, difficulty getting needed mental health care and other stressors.

“I think everybody’s anxious,” Sullivan explained. “The sense of security that all of us had 10 years ago is way less right now. There’s wars in places where there haven’t been wars. There’s things that are terrifying everybody — wherever you are on the political spectrum. I think that’s the human commonality.”

However, Sullivan said some population segments are disproportionately affected by suicide, with rates increasing fastest among people of color, younger people and people who live in rural areas. LGBTQ+ people and military veterans can also be at higher risk of suicide.

“There can’t be a one-size-fits-all suicide prevention,” Sullivan said. “Things have to be targeted to meet people where they are and at a certain point in time.”

Notably, firearms are involved in most suicides in North Carolina, accounting for 64 percent of deaths in 2021. This method of suicide exceeds the national rate of about 55 percent of deaths occurring by firearm.

Despite these sobering numbers, Sullivan said the good news is that based on research over the past 50 years, more effective suicide prevention strategies have been developed. The challenge, however, is implementing them.

State’s vision

Kody Kinsley, secretary of the state Department of Health and Human Services, told NC Health News that the state is focused on improving mental health and lowering suicides. The department created a state Suicide Prevention Action Plan in 2021 to guide its work, which includes initiatives to reduce access to lethal means of hurting oneself and to provide more crisis intervention services. 

More plans are in the works, including one being developed in partnership with the federal Substance Abuse and Mental Health Services Administration that is focused on the crisis among Black youth.

“Suicide is really, tragically, the last stop, on a long path of a lot of balls dropped,” Kinsley said. 

He recognizes that the state’s underfunded and overburdened behavioral health system plays a role in that, where a range of factors such as workforce shortages, long waits for inpatient psychiatric beds and poor reimbursement rates for providers affect access to care. 

But since taking over at the helm of the department in January 2022, Kinsley says he’s prioritized improving the state’s behavioral health system. He said his goal is to move the system from being in a constant state of crisis response to a state of comprehensive care that can help support people earlier — before they are in a crisis involving suicide.

Kinsley said significant investments over the past year have been crucial in inching closer to that goal. After a decade of cuts and slow budget growth, state lawmakers appropriated $835 million in the 2023 state budget over two years to address rising mental health needs — a sum touted as a “once in a lifetime” investment.

The funding — which came from a portion of the $1.6 federal billion sign-on bonus North Carolina received for expanding Medicaid — has already been allocated to a range of needs meant to help build a behavioral health system that works better, including increasing Medicaid reimbursement rates for behavioral health providers, adding more behavioral health urgent care facilities and expanding facility-based crisis centers.

For people in crisis, Kinsley said North Carolina’s rollout of the national 988 Suicide & Crisis Lifeline in July 2022 has been a crucial resource. The line is being used frequently, amassing more than 105,000 calls over 12 months, with 7,699 contacts coming to the state’s call center in April, according to latest data available on NC’s 988 Performance Dashboard. 

People who call or text 988 are connected to a trained counselor who will listen to their concerns, help de-escalate the situation, if possible, and direct people to resources in their home communities. A statewide Peer Warmline that launched in February also gives North Carolinians needing mental health support another place to call. The warmline is a noncrisis mental health support line staffed by peer support specialists who have experience living through and coping with mental health challenges and substance use disorder.

Kinsley said the state is also pushing to improve firearm safety to reduce access to the firearms used in most of the state’s suicides. It’s not a Second Amendment issue, he said; it’s about safely storing firearms so they are not accessible to people with mental illness. Gun locks and gun safes can help keep firearms out of the wrong hands and create a delay to one’s often rapidly escalating decision of suicide, Kinsley said.

“Many firearm owners own guns because they want to keep their family safe. I also want to keep their family members safe,” Kinsley said. “Whether it's due to suicide or accidental death, those are tragedies that are avoidable if we can keep those firearms stored safely.”

Community approaches 

While the state has strategies and resources in place to help reduce suicide deaths, Kinsley emphasized that community-led solutions are crucial. 

Counties across the state are stepping up, he said, sensing the need and urgency in their communities to curtail suicides that are often preventable. They are building coalitions involving health providers, government agencies, educational institutions, faith-based groups and nonprofit organizations.

The “Our State, Our Wellbeing” initiative invested about $500,000 to bolster community-led suicide prevention efforts, including strategies such as hosting wellness events to help normalize conversations around mental health, offering Mental Health First Aid training and distributing gun locks and medication lockboxes to decrease access to lethal means.

Many community efforts have emerged from tragedies that reflect the counties’ unique circumstances and at-risk populations.

Joyce Davidson from Cleveland County started to spearhead suicide prevention efforts in her community after her 26-year-old son died by suicide in 2022. 

“He was gay. He was married. He was struggling mentally, and he was struggling silently,” Davidson said. 

In the aftermath, she founded The Starr Project — named to honor her son using his middle name, Starr — as she felt motivated to spread awareness about suicide and available resources so another mother doesn’t face the grief she’s endured.

Similarly, Mindy Wonsick, a family physician in Ashe County, had noticed in recent years that more of her patients are dealing with mental health challenges and stressors — as early as elementary and middle school. But she was moved to take a more active role in addressing the mental health crisis beyond her patient care after a teen suicide in May 2023 shook the community and her own family. She had kids in the same age group and said she saw them struggle. 

Wonsick wrote notes to stakeholders all across the county, making an urgent plea that the problem could not go unaddressed. Based on the response from the community, they agreed. At the county’s first meeting about suicide prevention, Wonsick said about 75 people came. Now, there’s an Ashe Mental Health Forum that meets monthly to work toward addressing gaps in mental health support.

In Wake County, the Village of C.A.R.E. team tapped into what may seem like an unlikely place to reach people: barbershops. Bettie Murchison, who leads the group, said it’s been an effective setting. The group has distributed hundreds of gun locks there and trained more than 60 barbers in Youth Mental Health First Aid, she said. 

“Barbershops are like the Black country club,” Murchison explained. “You go there to find out what's going on and to tell what's going on with you. And so it’s a very social interaction, and people are comfortable there.”

In Transylvania County, the TC Strong team is going directly into schools to involve teenagers themselves in tackling the youth mental health crisis, forming Voice of the Students. The group is open to all middle school and high school students in Transylvania and provides an opportunity for youth-led strategies to support emotional well-being.

Saving lives

People at the summit report that some counties are seeing their efforts pay off with the formation of more safe spaces where people feel they can share their experiences without stigma. More community members are taking mental health training to be better equipped to engage in conversations and provide assistance. And significantly, they know that the steps they are taking are helping save lives.

Beth Ford, TC Strong’s director, said that just months ago when a Transylvania County teen learned of a peer threatening suicide on social media, they reached out to a TC Strong member who was able to use her connections to de-escalate the situation and get the teen connected to support.

“There was a school resource officer with the student within 30 minutes of us knowing about the threats that were happening on Snapchat,” Ford said.

“You always hear of a ‘bad game of telephone,’ and it was actually a really good game of telephone,” she added.

Ford said that example is a testament to how suicide prevention efforts — through building awareness of signs and symptoms, training people on how to help and providing resources to those in need — can save lives. 

And with 400 people attending the all-day suicide prevention summit, the desire and momentum to move the needle on the number of lives lost was palpable, so much so that Davidson — whose son died by suicide two years ago — said she teared up at least three times, moved by the energy in the room.

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