Editor's note: If you or a loved one are in crisis, you can call the National Suicide Prevention Lifeline at 1-800-273-8255 (1-800-273-TALK).

FARGO — Steve Dockter was so ill that his mother had to help him sit up in bed the day before he was discharged from the hospital.

He was admitted to a Bismarck hospital because he was so despondent that he was thinking of ending his life.

“He was in physical pain,” said his mother, Kora Dockter. He also was haggard — he’d lost more than 20 pounds — and pale. “He looked awful.”

But his psychiatrist determined that his mental condition was deteriorating in the hospital, so discharged him with what his mother, now a retired nurse, said was no real follow-up care plan.

Half a year later, on Feb. 21, 2014, she received a call from her husband informing her that their 33-year-old son was dead. Steve Dockter, a husband and father of three, had taken his own life.

“He made it about six months,” she said. She watched helplessly as her son’s condition worsened after he first tried to take his life in October 2012. He had lost hope.

Steve Dockter’s death — which his mother adamantly believes was preventable — was part of a rising number of suicides in North Dakota, which saw the nation’s largest increase in suicide rates from 1999 to 2016, 58%. That was more than twice the national increase, 25%, according to figures from the Centers for Disease Control and Prevention.

Minnesota logged a 41% jump in its suicide rate during the period, also well above the national increase. Only one state, Nevada, experienced a decrease over that time, a dip of 1%.

The finding that North Dakota led the nation in the increased rate of suicide galvanized action by state officials, but the state has long had suicide rates surpassing the national average. So has Minnesota.

Both states are implementing suicide prevention plans that focus broadly on education and awareness, including outreach to at-risk groups and teaching resiliency skills to public school students.

Also, health providers are increasingly engaged in suicide prevention, with many major health providers in the area embracing the Zero Suicide movement, with screening and follow-up care, based on the belief that anyone in the health-care system should not be lost to suicide.

Despite stepped-up efforts, suicide takes a grim toll in North Dakota and Minnesota. Consider a few indicators:

  • Suicide is the eighth leading cause of death in both North Dakota and Minnesota.

  • In North Dakota, which has the nation’s 10th-highest suicide rate, a person dies by suicide every 57 hours. In Minnesota, which ranks 38th, a person dies by suicide every 11 hours.

  • Suicide imposes real but hidden financial costs on society, a figure that topped $140 million in North Dakota and exceeded $759 million in Minnesota in 2017, according to the American Foundation for Suicide Prevention.

After several years of grieving her son’s death, Dockter has become active in working to improve suicide prevention efforts and now serves as the volunteer head of the North Dakota Suicide Prevention Coalition.

Much of her advocacy centers on improving the health system, so suicidal patients don’t slip through the cracks in the way her son did four years ago, despite his hospitalization.

Health providers recognize they are on the front lines in preventing suicide.

National research suggests that 45% of those who die by suicide visited their primary care provider within a month of their death. But nationally, health systems that have embraced the best practices of Zero Suicide’s preventive approach have seen reductions in their suicide patient death rates of up to 80%.

When Dockter’s son was discharged, she was stunned when she learned he was leaving without a discharge plan for follow-up care.

“There was absolutely nothing,” she said. “I was like, 'OK, now what?' In any other disease process, that does not happen.”

Until her son's suicide attempt, Dockter hadn’t known he was struggling with depression and self-destructive thoughts. In fact, she now knows, many who contemplate suicide hide their despair from loved ones.

It’s critical, according to Dockter and other suicide prevention advocates, to erase the stigma of seeking help for mental illness and to encourage those who are struggling to speak frankly about their distress and get help.

“It’s such a silent, lonely disease,” she said. “People don’t talk about it.”

***

One huge problem in curbing suicide: The health care system isn’t yet very good at identifying those who are at risk of ending their lives.

A psychology journal review of screening methods over the past half-century concluded that, overall, they weren’t much better than chance in identifying the suicide prone.

So, although 45% of those who complete suicide visit their primary care provider the month before, they come to the clinic with physical complaints, such as an aching back or knee, said Dr. Jon Ulven, a clinical psychologist at Sanford Health in Fargo.

“They’re not even talking about it,” he said, referring to their mental illness.

Experts and advocates agree that identifying a person at risk of suicide and getting the patient into effective treatment is a key to preventing suicides,

Promisingly, researchers using machine learning, a form of artificial intelligence, have devised a screening tool that is more than 80% accurate in picking those at risk for suicide, but the application isn’t yet ready for clinical use.

“The science is improving in this area,” Ulven said. “We’re in this spot of waiting a bit and the science is improving. It is a national problem and a science problem."

In both North Dakota and Minnesota, the number of suicides has increased steadily for more than a decade, according to state figures. Solving the problem is complex, because the risk factors for suicide are so varied and difficult to overcome.

People at increased risk for suicide include those exposed to violence and childhood trauma. They also include those suffering from serious mental illness, physical illness, alcohol or drug abuse, a painful loss, social isolation and with easy access to lethal means, including guns.

Both Minnesota and North Dakota are taking a public health approach to suicide prevention. Minnesota, in a suicide prevention plan introduced in 2015, set the ambitious goal of reducing suicide by 10% by 2020, 20% by 2025 and working toward zero suicide.

North Dakota, which also has embraced zero suicide as a long-term goal, is less specific in its goals, but like Minnesota is working toward eventually eliminating suicide.

Progress so far has been uneven in Minnesota, where suicide rates among females decreased by 10% in 2017 — but male suicide increased 18% in the seven-county Twin Cities metro area, though remained lower than the Greater Minnesota male suicide rate, state figures show.

Guns, the leading means of suicide nationally as well as in North Dakota and Minnesota, account for 54% of male suicides in Minnesota and slightly more than half of all suicides in North Dakota, according to the states.

In fact, ready access to firearms, along with increased social isolation and lack of behavioral health services, are among the reasons cited for higher suicide rates in rural areas.

“Frankly, it’s because of more access to guns,” said Sue Abderholden, executive director of the National Alliance on Mental Health Minnesota. “It’s often an impulsive act.”

Many who survive suicide attempts report that the decision was made rashly, when they were overcome with an intensely painful emotion within five minutes of acting on impulse.

Therefore, experts agree, an important way to prevent suicide is to remove convenient access to lethal means — such as safely storing guns or certain medications, perhaps by entrusting their safekeeping to a relative or trusted friend — to allow a potentially fatal impulse to pass.

Experts say preventing suicide will also require widespread knowledge of the warning signs, such as a concerning change in behavior or a person’s social withdrawal, and the willingness to ask that person if they are considering suicide — and, if so, helping them get support and assistance.

One widely accepted theory of why people turn to suicide identifies three key components: They believe they have become a burden to others who would be better off without them; they exhibit an unmet desire to belong; and they harbor an acquired capacity for suicide, manifesting in risk-taking and self-destructive behaviors.

The reasons that drive people to the extreme of ending their lives are complex and varied, studies show, usually involving multiple risk factors. Suicide rates have been increasing throughout the nation along with other signs of distress, including the opioid epidemic and alcohol-related deaths.

A major problem underlying those signs of despair and difficulty coping, according to Ulven: a weakening of social bonds that provide a support network.

“We’re less connected with each other,” he said.

***

Alison Wolbeck first tried to take her life more than three decades ago at the age of 12. Two years earlier, she had been sexually abused. Her family didn’t believe her.

The trauma of that abuse and her family’s reaction, she believes, is what triggered her mental illness, which cascaded over the years into at least a dozen attempts to end her life.

“I’ve lost count at 12,” she said. Now and then, the self-destructive urge returns. “It’s this persistent feeling that nothing’s going to get better.”

She kept her abuse a secret for two years, but gradually became comfortable talking about her mental health illnesses and suicidal tendencies.

“I think a lot of the stigma comes from people continuing to hide the issue,” she said.

Candid discussion is critical to breaking down the stigma surrounding mental illness, she said.

“A lot of people with mental illness perpetuate it,” Wolbeck said. “They don’t want people to know. I’ve been very open about it.”

Through decades of therapy and periodic hospitalizations, Wolbeck has learned coping skills, including having a small group of friends she can call when her mood blackens.

“I term people friend if they’re the people I can call in the middle of the night when the world is falling apart,” she said.

Wolbeck’s experience has taught her the importance of identifying mental illness early.

“We need to catch it and treat it, so it doesn’t turn into a lifelong disability,” she said. Although she has worked as a truck driver and construction worker, among other jobs, Wolbeck’s work now is limited to helping out at a recovery and wellness center.

She’s been left disabled by her illness, major depressive disorder with seasonal components, including frequent thoughts of suicide.

“It’s pretty much every day that I think about dying,” she said. “But whether that intent is there is the big difference.”

She has learned that getting involved in causes — mental health and suicide prevention advocacy, in her case — and her volunteer work help to maintain her mental health.

“People depend on me,” Wolbeck said. “I have responsibility. That kind of keeps me going.”

Wolbeck serves on mental health advisory councils both in Clay County and for the state of Minnesota. In the decade she’s been involved, Wolbeck has seen increased awareness of the human cost of suicide, but wishes more could be done.

“With tight budgets they try to do what they can,” she said of state and local programs. “It’s getting better. Nobody wants the taxes to go up. It takes money to do things.”

Local improvements include a 24/7 mobile response team by Lakeland Mental HealthSoutheast Human Service Center in Fargo has a similar program — as well as improved follow-up care to connect patients to appropriate services, Wolbeck said.

One big barrier locally, in her view: Patients in Minnesota can’t be transported by agencies across the state line to North Dakota, where Prairie St. John’s, a behavioral health hospital, is located. Instead, they must be taken 58 miles to Fergus Falls, Minn.

When in crisis, Wolbeck, who lives in Moorhead, usually drives herself to Fargo.

“If I had to drive myself to Fergus, I really don’t think I’d make it. That’s too much time to think.”

***

Everything seemed to be going on an upward trajectory in Sarah Dixon-Hackey’s life when she abruptly descended into crisis.

She had just graduated from Concordia College in Moorhead, Minn., with honors, was engaged to be married, and her career prospects looked promising.

“And I completely imploded,” she said, resulting in her first suicide attempt. “It was very counterintuitive to what most people would assume.”

With so much going on in her life, Dixon-Hackey had neglected to take care of herself. “I was completely depleted,” exhausted and in physical pain, combined with a sense of dread, she said. She had panic attacks and was developing stomach ulcers. “It was excruciating.”

Actually, her crisis in early adulthood wasn’t completely unexpected. Dixon-Hackey’s suicidal impulses started at the age of 12, and her stress and anxiety levels had gone up when she left home to attend college.

Dixon-Hackey, whose ancestry is South Korean, didn’t want to stand out more than she already did when she was growing up, so learned early in life to hide her struggles. Also, she had a tendency to shrug off her problems.

“You think I'll keep muscling through,” she said.

Luckily, friends took her in for medical treatment after her first suicide attempt. Even so, a few months later she made a second attempt. That convinced her to go home and focus on getting well.

The American Foundation for Suicide Prevention’s logo is a life preserver — an apt symbol, Dixon-Hackey said, since battling suicidal impulses feels like drowning.

In the 20 years since that crisis, Dixon-Hackey lost her fiance, lost her job, went on to lose several more jobs, had several counselors and tried a variety of medications.

An important turning point came when she took a job at an after-school program, which gave her a sense of purpose and made her feel needed.

A few years later, she participated in an Out of the Darkness walk, sponsored by the American Foundation for Suicide Prevention. By 2014, her involvement in the event grew and she became one of the organizers, again giving her a sense of purpose.

She’s got her life back on track, but her struggles continue.

“Sometimes it will just hit you again,” she said. “It’s an ongoing maintenance that we have to keep working on. I would never say that my mental health is going to be 100 percent. It’s going to be something I’m going to have to manage.”

***

The year 2005 is an obvious demarcation point for Mary Weiler as she gauges progress as an activist for the American Foundation for Suicide Prevention in North Dakota.

That was the year she lost her daughter Jennifer, who took her life at the age of 33. The tragedy spurred her family to become involved in prevention efforts, starting in 2006 with Fargo’s first Out of the Darkness walk.

This year, nine community walks and one campus walk, at the University of North Dakota, were held. That's a measure of the much broader public awareness, education campaigns and support groups now available statewide, she said.

“Ten walks throughout the state has an impact on many people,” she said. “It is difficult to measure how our work has given hope to people after a crisis in their lives, but there are many stories of how our work has saved lives.”

In 2005, little help was available for survivors of suicide loss. Support groups to help with loss were unavailable, and even medical professionals lacked training in suicide or how to support survivors, Weiler said.

“As a survivor of suicide loss, there definitely was a feeling of being abandoned or disregarded by the mental health community,” she said.

Today the environment is much different, with support available from churches, in workplaces and better awareness, Weiler said.

“It’s a very unique type of grief,” she said. “There’s no single cause, but it impacts everyone. It’s not selective. I hope people know that if they’re in crisis there is help and we can provide that help for them.”

***

One of the bright spots in working to reduce suicides is that the vast majority of those who survive an attempt — estimated at 90% — go on to get help and never die by suicide.

“I do find that encouraging,” said Alison Traynor, North Dakota’s suicide prevention coordinator. “If we can put time and distance between people at risk for suicide and the means, then we increase the chances for survival and recovery.”

But a major stumbling block remains. Experts still can’t explain why suicide rates keep climbing, said Abderholden of the National Alliance on Mental Illness Minnesota.

“I don’t think we know, which is why we want more research,” she said. One way to a better understanding, she added, would be to conduct more of what are called “psychological autopsies” to determine why people end their lives.

“I think that’s really important,” Abderholden said. “We need to do that.”

Although North Dakota hasn’t been able to show a trend of declining suicide rates, steps it is taking through its suicide prevention plan, written by the North Dakota Suicide Prevention Coalition, are laying groundwork, Traynor said.

Public school students around the state are gaining resiliency skills through a “Sources of Strength” program, and many health systems are embracing the Zero Suicide initiative, and more people have access to evidence-based treatments, Traynor said.

“We are going to be looking for that decrease in the coming years, but that takes time,” she added.

Other initiatives centered on changing behaviors, such as reducing underage drinking, have shown that addressing risk factors can produce results, Traynor said.

North Dakota’s budget to combat suicide has been stable in recent years at about $1.2 million per biennium. Although funding has been flat, a recent reorganization moved the program from the Health Department to the Department of Human Services, where there is more mental health expertise and an opportunity to work more closely with allied programs, Traynor said.

“It’s a big priority,” Laura Anderson, North Dakota’s assistant director of behavioral health services, said of suicide prevention. “This impacts family members and friends and communities.”

Money targeted toward other needs means only so much can be spent to prevent suicide, Anderson said. “The barrier is resource allocation,” she said, but suicide prevention will remain a priority.

Although it gets far less attention, Anderson said, suicide affects far more people than the opioid epidemic that often captures headlines.

North Dakota’s alarming rise in suicides is the most dire indication of a broader mental health crisis in the state, said Sen. Kathy Hogan, D-Fargo. Some of those suffering from mental health crises will resort to desperate measures if they are unable to get the help they need, she said, and gave as an example the tragedy of Astra Volk, the Grand Forks mother who last year killed herself and her three children.

After years of relatively low funding levels in Minnesota because of budget austerity, a consensus formed in St. Paul and now the state is embarking on a major push to prevent suicide, which last year claimed 780 lives in the state.

Officials were alarmed not only by the steady and years-long increase in suicide rates in Minnesota, but also increases in overdose deaths and alcohol-related deaths, problems that often overlap those at risk for suicide, said Amy Lopez, coordinator of Minnesota’s suicide prevention program.

“It was this kind of trifecta of, wait a second — what’s going on?” she said.

The initiative is budgeted for $2.5 million in 2020-21, increasing to about $4.5 million in 2022-23.

“This is the first really significant investment” in suicide prevention in Minnesota, said Mark Kinde, the state’s injury and violence prevention director.

One of the effort’s hallmarks will be to create more meaningful relationships and target specific groups, such as farmers and agribusiness people, he said.

“It’s very much a community-driven approach,” Lopez said. “We’re really trying to branch out into various sub-populations. There is hope. We do believe that most suicides are preventable.”