If you or someone you know may be experiencing a mental health crisis, contact the 988 Suicide & Crisis Lifeline by dialing or texting “988.”
Someone in America dies by suicide about every 11 minutes. It’s common, but not inevitable. Traditionally, suicide has been framed as a problem inside an individual’s mind — often attributed to mental illness. Over recent decades, however, experts and people with lived experience have pushed a broader question: what in someone’s environment pushed them toward that point?
For Chris Pawelski, a fourth-generation onion farmer in New York’s Orange County, the answer was a cascade of pressures. His father, his close friend and daily work partner, was diagnosed with renal cancer and died six months later. Pawelski became the primary caregiver for his mother, who has dementia. His family farm was losing money: some years he grew about $200,000 in crops but took home only about $20,000 because wholesale buyers held pricing power. Debt to suppliers and equipment vendors mounted, his marriage frayed, and he worked sunup to sundown seven days a week to try to keep the legacy alive.
“It’s all stuff collapsing down upon you,” he said. “It’s weeks, months, years of dealing with all sorts of pressures that you can’t alleviate.” He began imagining being hit by a truck driving by his house: “You think you’re already on your way out, so why wait?”
Millions of Americans have serious suicidal thoughts, and tens of thousands die by suicide each year. Suicide is consistently among the top 10 causes of death in the U.S., marking the country as an outlier among wealthy nations. Prevention efforts have historically focused on identifying people in crisis and connecting them to medical treatment, such as therapy and medication. But those services can be expensive, the behavioral health workforce struggles to meet demand, and research indicates suicide risk reflects many factors beyond clinical diagnoses.
A growing movement calls for expanding prevention beyond crisis response to address the social and economic drivers that give people reasons to keep living. Advocates say prevention should include things like food banks, social activities for isolated seniors, school programs that build resilience, and housing policies that prevent evictions. Decades of research show such upstream initiatives — even when they don’t explicitly target mental health — can lower suicide rates and also reduce crime, addiction, and poverty.
Sally Spencer-Thomas, a psychologist and suicide-prevention researcher who lost her brother to suicide, said the logic is simple: “If you have happier, healthier people, they live longer, happier lives.” She argues prevention shouldn’t be limited to hotlines or psychiatric wards but should include social programs and policies that build stable, connected communities. The U.S. has lagged other countries in adopting this approach, she said, in part because it’s easier and more politically palatable to promote therapy than to pursue sweeping policy change, such as raising the minimum wage. “As long as we have that convenient narrative that it’s just a bunch of broken people needing medicine and treatment, then we’re never accountable for fixing the broken things in our communities,” she added.
Shifting prevention upstream can be politically and financially challenging. It often requires large investments and long-term commitments that don’t yield quick, visible metrics for elected officials. Yet some analysts and federal officials say elements of an upstream strategy are gaining traction. Allison Arwady, director of the Centers for Disease Control and Prevention’s injury center, emphasized building systems that support people regardless of circumstances, noting “there’s always going to be turmoil in people’s lives.” Brandon Johnson, who leads suicide prevention work at the Substance Abuse and Mental Health Services Administration, has pointed to programs promoting youth physical and mental well-being and partnerships with community and faith organizations as avenues that can reduce risk.
The covid pandemic sharpened attention on environmental drivers of distress: rates of anxiety and depression rose as the world around people changed. The launch of 988 in July 2021 — a shorter national number for suicide and crisis support — channeled funding and attention into crisis response systems, including call centers and mobile crisis teams. Monica Johnson, who led federal work on 988, said the improvement in crisis infrastructure has been important but cautioned that “you’ll never be able to build a system based on crisis alone.”
Policy choices also influence risk. Critics say recent federal actions that reduce access to health coverage, food assistance, or community supports can heighten stress and desperation for many people. Hannah Wesolowski, chief advocacy officer at the National Alliance on Mental Illness, said such changes can cause “extreme stress and anxiety” that raise the likelihood of crises. Federal agencies, meanwhile, note some policy priorities align with upstream prevention: for example, initiatives encouraging youth physical activity can improve mental health, and programs that connect people experiencing homelessness to treatment can address risk for a high-risk population.
Still, budget cuts and staff reductions at key public health agencies have raised questions about sustaining prevention efforts. The history of U.S. suicide prevention has tended to emphasize medical and crisis care. In the late 1990s, as youth suicide rates grew, government and advocacy groups produced national strategies that primarily focused on identifying people in crisis and expanding access to treatment. Those remain crucial. But many experts say focusing only on individual treatment misses how life circumstances trigger or worsen mental illness — things such as job loss, bereavement, childhood trauma, or economic instability.
The story of Pawelski illustrates how a broader approach can work in practice. By 2020, cheap imported onions depressed prices and left him with substantial losses. He and his wife decided they couldn’t afford to plant onions again. The prospect of the farm ending with him was “soul-crushing.” He lost weight and contemplated suicide.
They called NY FarmNet, a free Cornell University–based program founded in 1986 that pairs farmers with two consultants: a financial analyst for farm planning and a social worker for emotional and family issues. The financial consultant helped Pawelski craft a new business model: rather than competing in wholesale onion markets, shift to small-scale vegetable production (greens, tomatoes, peppers, eggplants) for direct-to-consumer sales, upgrade a truck with a cooler for deliveries, and diversify income with teaching and speaking using his communications master’s degree. The social worker helped him process the emotional loss and accept a new path — a psychological shift Pawelski said was as important as the business plan. He also saw a therapist during the transition.
The change took months. A neighbor later remarked on how much happier Pawelski seemed, a transformation that surprised him. Today his business is more stable, he and his wife are paying down debt, and he advocates for programs that address farmers’ mental health and the structural pressures they face, such as fair pricing, debt relief, and rural broadband access.
Pawelski sees crisis hotlines and affordable therapy as necessary parts of prevention, but he argues they aren’t sufficient: “We need to think broader and longer-term than a helpline,” he said. “That’s a band-aid on a gunshot wound.”
Experts say a comprehensive suicide-prevention strategy should include both strong crisis systems and upstream investments that reduce the conditions that foster despair. That means integrating clinical care with policies and community programs that secure housing, food, work opportunities, social connection, and economic stability. Together, those efforts can give people both the help they need in a crisis and the reasons to keep living.