States of Despair: Understanding Declining Life Expectancy in the United States

12:00 p.m. – 12:10 p.m.          Welcome and Opening Remarks

• Sarah J. Dash, MPH, president and chief executive officer, Alliance for Health Policy (@AllHealthPolicy)

12:10 p.m. – 12:50 p.m.          Panelist Opening Remarks

• David Radley, Ph.D., MPH, senior scientist, Tracking Health System Performance, The Commonwealth Fund
• Marvin Figueroa, Ed.M., deputy secretary, Office of the Secretary of Health and Human Services, Commonwealth of Virginia
• Joe Thompson, M.D., MPH, president and chief executive officer, Arkansas Center for Health Improvement; professor, UAMS Colleges of Medicine and Public Health, (@JoeThompsonMD)
• Richard McKeon, Ph.D., MPH, chief, Suicide Prevention Branch, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration
• Anand Parekh, M.D., MPH, chief medical advisor, Bipartisan Policy Center

12:50 p.m. – 1:30 p.m.                        Question and Answer Session

  Note: This is an unedited transcript. For direct quotes, please see video: http://allh.us/xtDV   SARAH DASH:  Good afternoon, everyone.  Thank you so much for joining us here today for a briefing called States of Despair:  Understanding Declining Life Expectancy in the United States.  My name is Sarah Dash, I’m President and CEO of the Alliance for Health Policy.  And for those who aren’t familiar with the Alliance, we are a non-partisan organization that is dedicated to advancing knowledge and understanding of health policy issues.  So we thank you all for being here today to better understand this issue.  Hello as well if you are following on Twitter using the hashtag #allhealthlive, and folks can feel free to submit questions by Twitter, and they will be brought up here. Before we get started, I would like to thank the Commonwealth Fund for its support of this briefing. So the terms “Deaths of Despair”; deaths from suicide, alcohol and drug abuse, is a relatively new term. However, it’s a complex term with a lot of underlying issues.  And today we hope to help unpack this term, and the underlying trends, and understand better how deaths of despair relate to trends in declining life expectancy in the United States.  We are also going to highlight the development of state and federal policy solutions to address these trends.  You are going to hear from five excellent speakers and I know there are only four of them up here right now, we are waiting on the fifth who is — had a delayed flight, so if anyone does transportation policy as well, feel free to chime in. But he should be here momentarily. So that’s why we are going to get started. Our speakers are each bringing a very different perspective to this issue, and we are really grateful to have them shed light on this critical topic. I’m not going to be able to do their background justice in the short time that I have, so please do check your packets for their bios with more extensive information. I will briefly introduce them, and then we will get started. So joining us today, to my left, we have David Radley.  David is a senior scientist for the Commonwealth Funds tracking health system performance program. He and his team develop analysis on healthcare system performance, and related insurance, and healthcare system market structure analysis. He co-authored the 2018 State Scorecard on Health System Performance, and we are grateful that he’s going to help us explain the methods behind that report and what it showed.  Next we’ll have Marvin Figueroa. Marvin is Deputy Secretary of Health and Human Resources for Governor Ralph Northam in Virginia.  Prior to his appointment, he served for seven years as senior policy advisor for Senator Mark Warner, and I understand was also a college counselor at some point in the past, so has perhaps helped people through some challenging times in their lives. Marvin is going to provide some on-the-ground perspective on these trends and what is going on in Virginia. Following Marvin, should he arrive in time, we are going to hear from Dr. Joe Thompson, who is going to provide another state perspective on deaths of despair. Joe is President and CEO of the Arkansas Center for Health Improvement, and he’s responsible for developing research activities, health policy, and collaborative programs that promote better health, and healthcare in Arkansas. Next, we will hear from Richard McKeon, who is Chief for the Suicide Prevention Branch, in the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration, or SAMHSA.  Richard is going to provide insight into SAMHSA’s purview over issues related to deaths of despair, as well as their suicide prevention efforts. Finally, we will hear from Anand Parekh, who is the Chief Medical Advisor of the Bi-Partisan Policy Center. And prior to joining BPC, he completed over a decade of service at the Department of Health and Human Services.  We are thankful that he can use his expertise to provide some summary remarks and he will draw on some of his work form the article Towards the United States of Health, that looks at the global burden of disease across state healthcare systems. So with that, I am going to turn it over to David Radley, to kick off the conversation. Thank you.   DAVID RADLEY:   Can you guys hear me okay?  Thanks, Sarah, and thank to the Alliance for putting this meeting together today. I think it’s an important topic, and I’m happy to sort of lay out some high level data just to sort of do some context setting for you, and then the experts on the panel that really sort of know the issues a little bit deeper than I do, will dig in. But anyway, my name is David Radley; Sarah said I’m Senior Scientists at the Commonwealth Fund, and a Senior Study Director with West STAT. And I’m responsible for the Commonwealth Fund’s health systems score card reporting series. Today, I’m going to be presenting data from our most recent state scorecard, which came out in May, and also from a blog post that we recently published on the Fund’s website just a couple of weeks ago, that takes a deeper look at Deaths from Despair.  Deaths from Despair is a measure that we included in our 2018 state scorecard, and the blog post just digs a little deeper on that particular measure. The data that I have, that I will be presenting today, don’t get too caught up if you don’t see all of the number — if you can’t keep up with the numbers on the screen. You have the data, it’s in your packet. The blog post has a table in the back, and all of the data that I’m going to be talking about, you have in front of you, so if you get lost, don’t worry, you have the material. So the Deaths from Despair measure is part of scorecard reporting series. We have been doing this series for about ten years, and the formula has really stayed about the same over those ten years. We look at 30 to 40 performance measures spread across five dimensions of care. We look at healthcare access, healthcare quality, efficiency, healthcare equity within states, and then population health outcomes. We started the series with a national report that basically looked at U.S. averages compared to international benchmarks, but we’ve grown the series to look at state and even local level data, and even a couple scorecards looked at special populations of interest. Today, we are going to focus on just one measure, the Deaths From Despair. So Deaths from Despair isn’t a clinical term, per se. The term was actually coined by two economists from Princeton a few years ago, in some work they were doing to look at health outcomes associated with sort of broad economic and social trends. When we’re talking about deaths from despair, we are really talking about a composite of deaths from alcohol, suicide and drug overdose. So in suicide, these are basically any death that occurs of self-injury, and actually can include — our definition can include intentional drug overdoses; taking drugs with the intention of killing themselves, if there was some sign that that was the case. Alcohol related deaths are basically deaths that result from some sort of liver disease, alcohol use, and then I think what we are most interested in today is deaths from drug overdose. In this definition that we are going to be talking about today, we are talking about drug overdoses that include opioid deaths, but that aren’t limited to opioid deaths. This definition can also include deaths from adverse drug events, from prescription, or even over-the-counter drugs. So just for a little bit of a context setting, if we look back over the last ten years or so, deaths from despair has been a leading cause of death to be sure, but still far few people in our country are killed each year from deaths from despair than are killed from heart failure or cancer. What is unique about this Deaths from Despair measure, is that it’s the only leading cause of death that has actually increased in the last ten years. So deaths from heart disease are down, deaths from cancer are down, stroke — everything is down. All of these major deaths, tied to a lot of these major chronic diseases, are all trending downwards, which is of course what we would hope from our healthcare system. But deaths from despair are going up, and they are actually going up a lot. In this chart you can sort of see exactly — you sort of can see that increase a bit better. In 2005 to 2016, deaths from despair rose over 50 percent nationally. What’s really driving that is a huge increase in deaths from drug overdose. So drug-related deaths are up, they’ve more than doubled over the last decade. Deaths from drug overdose have far surpassed suicide and alcohol use as the leading contributor to sort of this composite of deaths from despair. We are going to focus on opioid deaths, and certainly that is the topic of the day, rightfully, it deserves a lot of attention. But don’t lose sight of the fact that suicides and alcohol deaths are still up, over 20 percent, in the last ten years. I mean, these are still big increases, and these are still important topics that deserve attention. Let’s take a look at what’s going on across states. These national trends are concerning, but it really doesn’t hit home until we are thinking about what’s going on across states. So if we go back to 2005, we are looking again at the composite measure of deaths from despair. If we go back to 2005, not a single state had an overall deaths from despair mortality rate higher than 50 deaths per 100,000 individuals, and 26 states, plus D.C., were all under 30 deaths per 100,000 population. By 2016, the map looks quite different. By 2016, only one state, which was Nebraska, was under 30 deaths per 100,000, and the whole country has shifted, and now by 2016, 18 states plus D.C., so 19 total, were up over 50 deaths per 100,000 individuals. West Virginia has fared far worst than the other state. Their deaths from despair rate is over 80 per 100,000 now. And here, we can sort of get a sense for just how sort of concerning the trend is West Virginia is. So what I’ve done here, each of the gray dots is the state rate, and overall deaths from despair for the year that is indicated across the bottom. So you can sort of see the full range as a distribution for the states. And if you go back to 2005, West Virginia was just a little bit higher than the national average in this overall composite of deaths from despair. Through 2009, through 2010, there was sort of a steady increase, a little bit of an anomaly in 2009. But then from 2012 through 2016, with a real inflection right around 2014, you can see just how steep that increase in West Virginia in deaths from despair is. And when we look at what’s causing it, it really is drug overdoses. So in this chart, we are looking — I’m comparing Nebraska and West Virginia. These are the states with the lowest and highest rates of deaths from despair in 2016. When we look at Nebraska, there was sort of a modest increase between 2005 and 2016 for each of the components of deaths from despair, but for West Virginia we see a modest increase in alcohol deaths, a modest increase in suicide deaths, but an absolutely staggering increase in drug overdose deaths, which of course is driving the overall composite. Just a quick summary: Deaths from despair are up in every state, they are up nationally, the trends are concerning. Deaths associated with drug overdose are the primary contributor to that, and even though ten years back they were the smallest contributor to the overall composite in deaths from despair, by 2016, now they are by far the leading contributor. State experiences are very different. There is much different things going on, and it’s a problem everywhere, but different states are being impacted much differently by this. And so the other panelists will talk a lot about the policy implications, but at a very high level, I think we sort of an opportunity to be thinking about improving access to opioid reversal medications. I think there is an opportunity to be more proactive with opioid prescribing guidelines, and in fact, limiting opioid prescribing rates. And there is of course opportunities to enhance people’s access to mental healthcare services, and to encourage care delivery models that integrate behavioral and medical care into one model. That’s it for me. Just a real quick shout-out to Susan Hayes who is in the audience, who is actually the lead author on the blog post you have, and to Doug McCarthy, another one of our fun colleagues, who’s done a lot of work on this topic with us. Thank you. MARVIN FIGUEROA:   That was a pretty segue.  Good afternoon everyone, my name is Marvin Figueroa, I’m the Deputy Secretary of Health and Human Resources for the Commonwealth of Virginia. Before I became secretary, I spent seven years working for Senator Mark Warner. So in large part, this feels like somewhat of a homecoming. So I really want to thank the Alliance Health Policy team for welcoming me, and Sarah in particular for inviting me. I’m going to start off my segment by showing you this Health Opportunity Index. It was put together by the Department of Health in Virginia, and it’s a composite of about 13 indices, that takes into account about 13 social determinants of health. So it’s everything from education, food insecurity, job participation, income, and equality. And the case that I want to make today, is that when you think of — these are more death of disparity. I will show you maps later on where you can see how they track each other, but in large part, what has resulted in these deaths of despair, is exactly the disparity that we see across the Commonwealth. I want to particularly bring your attention to the blue and the pink. None the less, understanding the factors responsible for recent mortality trends, is important for us to address the possible health crisis, and also think through what are the underlying causes. So just a slightly different definition. When we think about death of despair in the Commonwealth of Virginia, we are looking at a particular population. That is what I will focus on today. It tends to be white, non-Hispanic. 25 to 50 years old, and the stressful conditions that Dr. Radley mentioned are the same — so unintentional drug overdoses, suicides, alcoholic liver disease, and alcohol poisonings. So we take, say, 1992 through 1995, and we take 2010 through 2014, and look at the percent increase in mortality rates, there are a couple of things that we will observe. The death rates from unintentional drug overdoses increased by 331 percent. Death rates from alcoholic liver diseases increased by 37 percent, and the suicide rate increased by 29 percent. And not on the graph, but worth noting, is that a condition responsible for the increase in mortality rates have to do with organ diseases. So everything from bio hepatitis to heart diseases, many of which have a potential link to substance abuse and other trauma. But these deaths are not evenly distributed in the Commonwealth of Virginia. Remember that health opportunity index? The higher stress rates of mortality rates are in Southwest, are at West Central, which borders Kentucky and West Virginia on our south side. These populations have the lowest and second lowest median household income, highest unemployment rate, and more than one in four children live in poverty. Taking a deeper view of things, the sharp increase happened in — is 262 percent, 245 percent, 215 percent at Wise County, County, and Dickenson County. Thinking about social determinants of health, in Wise County, 49 percent of adults graduate from high school, and Buchanan, only 9 percent of the population has a bachelor degree. 31 percent of the children there live in poverty. If you look at Eastern Virginia, they had the largest proportional increase in these type of deaths. Lowest percent of high school graduates, largest shortage of mental health professionals, and the second highest unemployment rate in the Commonwealth And what do you know? What do you see? The rates of the fatal prescription opioid overdoses tend to happen in those locations as well. This is excluding Fentanyl, this is including Fentanyl. What we see from the federal government these days is a reaction to this. So we have a number of different grants that have been awarded to the states. I apologize for all the text, but the biggest takeaway here is that because of the opioid crisis, we are receiving more financial resources to be able to combat this issue. But the challenge for states is how do you look at opioids and look at substance abuse, and try to create a system or infrastructure that responds to addiction, regardless of the substance. For us, the way ahead means that we have to move away from the immediate response to a crisis, which is often to just react. And more look at the systematic approaches to be able to address this issue. In the time that I have remaining, I’m going to focus on four topics in particular. One is, Virginia has what we call community service boards, and its in the code of Virginia, and the responsibility is provide intellectual disability, mental health, substance use disorder services either directly or through contract with private providers. We have about 40 CSBs scattered across the Commonwealth, and what you will found is that depending on what CSB you are in, you will see different quality, and different types of services. So if you’ve seen one CSB, we say, you have seen one CSB. Part of our strategy to transform a mental health system, is to integrate behavioral health, and primary care, emphasize population health and awareness, excellence in behavioral healthcare, and also sustained strategic investment in community service, and supports. What we call STEP Virginia. So what you will see on the right hand column is kind of what we are building towards. So we are making strategic investments to make sure that regardless of where you are in the Commonwealth, you will be able to receive these services. Secondly, we are taking a closer view on our Medicaid population and working with the American Society of Addiction Medicine, have created a benefit that we call ARTS. And ARTS encompasses evidence based services that we know are useful for individuals who have SUDs. So that is a full spectrum of addiction and treatment services that include residential treatment, case management, peer recovery counseling, and most importantly, demonstrating the commitment that the general assembly and the governor had made, that we also increase reimbursement rates for behavioral health and mental health services. The result is that we have seen treatment rates increase, we have seen the number of members receiving pharmacotherapy for opioid use disorder increase by 34 percent, and we also have more practitioners able to provide services. Here is a graphic of the impact that we’ve seen. So this is before ARTs, this is after. Finally, trying to bridge the gap between our public safety secretary and our health and human resources secretary, we formed an executive leadership team that brings together the secretaries to kind of combat substance abuse writ large. Here are some of the initiatives that we have going on, so everything from how do you get justice involved interventions, the treatment, to prevention, to supply prevention and harm reduction. And we can talk about that a little bit later during the Q&A. Then finally, we are focusing on average childhood experiences. One, most of the time, when we serve these individuals, we acknowledge that there are different issues that they’ve gone through, that have caused traumatic stress. They have manifested themselves in some form of abuse, and the governor’s goal at this point, is to try to figure out how do you include trauma informed counseling in education, and also in healthcare? We also have to think through the fact that a lot of these individuals, in particular those regions where we’ve seen these higher mortality rates, that they have children sometimes. And what do we do to ensure that the children also don’t become substance use abusers. We have Medicaid expansion in Virginia, and so more people have access to the ARTS program. I’m just including that to talk a little bit about — to put that as a post we can talk about later. And then these are the challenges. And it all has to do about funding most of the time, but also, what are the changes that we can make because of this increased funding, to allow us to better serve these individuals, where they present, and provide the right care at the right time. Finally, this is a note that we received from one of our constituents:  So, less addictive drugs — we need less addictive drugs, people are committing suicide because of drugs, and they are getting diseases because of drugs. Our children are watching. Thank you. SARAH DASH:  Thank you.  Marvin, before we go on, I just want to ask:  Could you talk a little bit more about the impacts of Fentanyl on the death rates you showed slides with, and without, and just wondering, you know, there’s been some talk about that being the driver of some of the deaths, and of course if anyone else wants to chime in, but just wanted to ask you what’s going on there. MARVIN FIGUEROA:   Well, what we observe is that it all depends on where — what locality you are in.  So depending on the locality, you will see either the biggest drive being Fentanyl, you have other little places where it’s heroin, and other places where it’s Methamphetamines.  So again, the biggest takeaway is a drug will always find some — will always be different depending — well, let’s start over.  If you are a substance abuser, you will find a drug to abuse. And so we have to figure out, not necessarily how to react to the drug itself, but reacting to the underlining causes that are causing that individual seeking that drug. SARAH DASH: I think next we have Dr. Joe Thompson.

1. JOE THOMPSON: Great. Thank you for the invitation, to the Alliance, and support from the Commonwealth Fund, and fellow presenters, I’m honored to be here on the platform with you, and to all of you for being here today.

By way of background, just for information, I’m a physician, I lead the state’s unofficial health policy center. For ten years I served as the lead cabinet advisor to former Republican Governor, Huckabee, and Democratic Governor Beebe. So these issues have emerged over the last decade, and I have had upfront and important kind of opportunities to see the death and despair that we are talking about today. I will start by just one of the fundamental outcomes that I’m going to share with you:  zip code matters. The deaths of despair are concentrated in areas of our nation, and areas within our states, which despair is not just about mental health depression, it’s other opportunities, it’s the erosion of the community fabric, it is the out migration of individuals from small cities in rural America that is leading a fabric of despair, that can subject individuals to turning to drugs or alcohol, or other escape mechanisms that we’re talking about here today. So let me give you a state specific perspective, and I have to start — Arkansas is always — or has always been in the bottom two or three of state’s health rankings. We compete with Mississippi — anybody here from Mississippi and Louisiana?  We are there with you. We were one of the few states that in 2014 took the Affordable Care Act opportunity, and expanded Medicaid. The only southern state that expanded Medicaid. And to just share with you, it does make a difference. It’s not often that within a year you can see graphical displays that are state’s boundaries for the dramatic reduction in uninsured that we have. Specific to this topic, importantly, it forced our insurance carriers to cover mental health and substance abuse, which most of them did not do prior to 2014. As a point of advertising again, our rates, because of the way that we did it, through Medicaid, large purchase in a small individual marketplace, had been lower than other state’s experiences.  And our competition has increased. We’ve gone from one carrier statewide, to now we have three carriers statewide, and the increase in choice. And so we had the financial mechanism in place, but we still had the challenges of the topic that’s on the table today for our deaths of despair. This is for the Institute for Healthcare — Health Metrics and Evaluation, from the University of Washington. These are mortality statistics.  The darker red color are where mortality rates per 100,000 all cause, are greater. And you can see in areas of our nation that had economic depression in rural areas, and areas that had not benefited from some of the expansion and some of the technology advances of the coast, or of our larger cities, you have significantly higher mortality rates. Along the lower Mississippi River Delta, Arkansas, Louisiana, Mississippi, we have statistics that rival third world countries for the entire state, on virtually every health statistic, and unfortunately, in the federal government, when you look at health statistics, the Mississippi River is used to divide the Eastern Region and the Western Region, so that you never really see how bad it is on either side of the Mississippi River, because those health statistics are diluted by higher functioning cities to the east and west. It’s focused in poverty. The median household income, if you line all the households in Arkansas up, is $44,000 a year. That includes the Walton’s, who are some of the richest individuals in the country, so you can get an idea, here in Maryland, it’s about $87,000 a year. If you go out into those rural areas of the state, and it’s not just Arkansas that has these rural challenges, it’s the entire nation. You have a significant economic depression, and many of those families lost much of their net worth during the recession a decade ago, and they have not regained it. So these are stimulus for individuals turning to substances of abuse, and the drugs that we are talking about. You already saw this:  We are one that is experiencing a higher death rate, although not yet to the extent of Kentucky. However, we are the second highest prescribing state in the nation with more than one prescription per individual each year, of opioids. We have attacked this, and I will share with you what we are doing well, what we are trying to do better, and what I believe we have yet to do, and I think this is a nationwide call. We have established and had one of the more robust prescription drug monitoring programs, that we have required physicians to access the PDNP prior to prescribing a schedule 2 or a schedule 3 narcotic. We have active surveillance of the PDNP, the Health Department has mailed out letters to providers that are outside of the norm for their practice characteristics. We have statewide and local drug takeback programs. We have a significant level of effort under Public Outreach in Education. We have payer engagement strategies on both the public and the private side. Our state and public school employee’s plan, the largest health insurance plan in the state, limited nascent, or first time narcotic prescriptions to 7 days in an attempt to try to avoid a longer term exposure that leads to addiction. Our College of Pharmacies, one of the leading investigatory units in the nation, supplying the CDC with much of their “how long it takes you to get addicted”, which is between three and five days of consumption. Our Medicaid program has limited the Morphine milligram equivalents, there are prescribed on nascent prescriptions, and also required lock-in to a single pharmacy for Medicaid paid drugs. So I think we are moving on the public and the private side. This is an example. On your right are the Medicaid bill rates for beneficiaries. On the left, where the commercial sector is lagging, you can see far higher consumption of opioids on the commercial sector, some four to five fold higher on the adult commercial, compared to the adult Medicaid program. We’ve got new and promising interventions underway with physician engagement; our medical board has actually now put a requirement that if you are over the CDC recommended Morphine milli equivalents, you must have in the patient’s chart a rationale for that, and a treatment strategy to try to lower that level of prescribing. As well as other review activities at the Medical Board. The Employee Assistant programs, I think every employer — large and moderate size employer — has an employee assistance program. I think this is an area we are not actively utilizing. We have tens of thousands of individuals currently addicted, and dependent upon narcotics. We have a number of efforts going to turn off the supply. But if we don’t have the mental health treatment, and the addiction recovery efforts in place, we are going to drive people to more elicit drug use, which we have yet to experience in a significant way as have other states, I think, on either coast. A new effort, a crisis stabilization units, these are efforts at four counties within our state to put a medical three day way station between individuals who are picked up by the police, and on their way to jail, to try to stabilize them for a mental health perspective, or potential substance abuse issue, rather than incarcerating them and taking them down a path that we know leads to recidivism and poor health outcomes. So these are efforts going forward. I think we have some gaps, and some policy interventions that are still needed. We need coordination within the state across payers. I mentioned the commercial side, and the Medicaid side, but they need to get together to reinforce the consistent messaging to providers. We need coordination between states — Missouri does not participate with the PDMP, and so our residents that go across, we lose line of sight. When individuals on the northern border of Arkansas go into the southern border of Mississippi. Medicaid, although the expansion is required to cover substance abuse, traditional Medicaid in our state, and in many other states does not cover substance abuse as a covered benefit. That’s why I think that is a challenge. And Buprenorphine availability is limited. I think there are waivers under my DEA card that we have too few physicians that have sought to be able to do substance abuse treatment. And the barriers to the number of individuals, even if I had a waiver, that I’m able to care for, it’s not going to match up with the demand that we have in our population. So with that, let me close. I look forward to questions and answers. There are good things going on, there are challenges going on. Zip code matters, and I think we need to go upstream; not just think about the supply line, but also think about the treatment line for individuals that are addicted. Thank you. SARAH DASH: Thank you. Dr. McKeon?

1. McKEON: It’s a pleasure and an honor to be here with you to talk about this important issue of deaths of despair, which SAMHSA has really tried to focus on. In fact we invited (indiscernible) to SAMHSA and arranged involvement with MIH and IAAA, (indiscernible) HERSA, VADOD, so that we could all talk together about this important issue, because of the increases. And while SAMHSA has been heavily engaged in the response to the opioid crisis under the leadership of our assistant secretary Elenore , who is an addiction psychiatrist. I’m going to focus with you on the issue of suicide. It’s only in the last couple of years that the deaths from opioids have overtaken the deaths by suicide, but suicide is also increasing in an alarming manner.

So there are nearly 45,000 people lost to suicide in the United States in 2016, the last year for which we had data. And of equal concern, suicide has increased in 49 of the 50 states, only Nevada has not seen an increase, and Nevada had one of the highest rates of suicide beforehand, and has not really gone down. More than half of all states have seen more than a 30% increase in suicide. So that is really important. And while mental health conditions play a very important role, those with serious mental illness, youth with serious emotional disturbance, have much higher rates of suicide than others. Suicide is complex, and there are multiple factor