The number of kids who struggle with thoughts of suicide – or attempt to kill themselves – is rising. New research, published Wednesday in Pediatrics finds children ages 5-17 visited children’s hospitals for suicidal thoughts or attempts about twice as often in 2015 as in 2008.

The study found kids of all ages are affected though increases were greatest for older adolescents.

Lead author Gregory Plemmons, a pediatrician and researcher at Vanderbilt University in Nashville, Tenn., says the study results confirmed what he’d been seeing at the hospital.

He says he hopes clinicians and families take note. “The number one thing to take home is that it’s important to talk about this and important to ask about it,” he says.

The findings line up with past data showing a steady increase in teen suicide over the past decade. The Centers for Disease Control and Prevention reported last year that a drop in adolescent suicide in the 1990s and early 2000s reversed course in 2008, though it’s not yet reached peak levels seen in the 1980s. It’s not clear what has contributed to the increase, but the study noted the 2008 financial crisis may be one factor among others.

Plemmons and his co-researchers examined 2008-2015 billing data from a database of 49 children’s hospitals across the U.S. They included all emergency department encounters, stays for observation and inpatient hospitalizations at those hospitals, but did not include community hospitals.

The researchers turned up 115,856 visits for suicidal ideation or attempts, during the seven-year period. Such visits represented 0.7 percent of total children’s hospital visits in 2008 but by 2015 had increased to 1.8 percent of all visits. More than half the visits required at least one night of hospitalization, and nearly 1 in 7 required intensive care.

Older teens were more likely to end up in the hospital and had the greater increase in hospital visits. About half of suicide-related hospital visits for the time studied were from teens ages 15-17, but 12- to 14-year-olds closely trailed them, making up 37 percent of visits. Children ages 5-11 made up the remaining 13 percent.

One of the study’s most striking findings was a seasonal trend in hospital visits. Throughout the years, visits peaked in mid-fall and mid-spring and fell to the lowest point in the summer. “We knew there was an association with school seasons, but actually seeing that mapped out was surprising,” says Plemmons. It suggests a link with school pressures.

“It really speaks to the stress and the strain at school,” says Dr. Robert Dicker, associate director of Child & Adolescent Psychiatry at Zucker Hillside Hospital in Glen Oaks, New York. “Kids appear to be under much more academic success to achieve and their perception of falling short.”

Dicker, who was not involved in the study, also noted possible influences from the media, particularly social media.

Plemmons also drew attention to social media’s influence. “You’re becoming more disconnected and not having relationships with real people, and at the same time you’re being fed a false distortion of what reality is, where everything looks great on screen,” he says.

Cyberbullying and sexting he adds, could also be risk factors. “These kids have to deal with pressures that we didn’t deal with.”

Other possible contributors noted in the study included earlier puberty in girls, since reaching puberty is a risk factor for suicide. Girls made up two-thirds of the hospital visits in the study period.

But none of these possibilities is definitive.

“This type of study is very good at revealing trends but cannot address causality,” says Dr. Laurel Williams, chief of psychiatry at Texas Children’s Hospital in Houston, Texas. Despite being the third leading cause of death in adolescents, suicide is still relatively rare, making it harder to study causes, she says.

But it is important to screen for depression and anxiety, she says. Her institution also uses validated screening tools to screen adolescents and is exploring tele-consultation strategies to help pediatricians manage cases if they feel underprepared or uncomfortable.

“We know there are a lot of patients still out there who have clinical depression who are not accessing care,” Plemmons says, adding that it’s important for adults to identify resources in their area for struggling teens. Parents can start with their child’s primary care doctor.

But the most important first step is one anyone can take.

“The current best method for identifying risk is to ask,” Williams says. “Asking a young person how they are feeling, not just how they are doing, is essential. We need to give young people the time and space to talk about how they are feeling. This involves developing closer relationships over time, not something you can scramble at the last minute or only in moments of crisis.”

Plemmons also emphasized the importance of talking to adolescents about the issue.

“There’s still a huge stigma and anything you can do to destigmatize it helps,” he says, adding that a fear still exists among some pediatricians and parents that discussing suicide may suggest it to adolescents.

“We know from literature that that’s not the case,” Plemmons says. “Talking about it can sometimes help reduce the risk.”

If you or someone you know may be considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (En Español: 1-888-628-9454; Deaf and Hard of Hearing: 1-800-799-4889) or the Crisis Text Line by texting 741741.

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Health and Human Services Secretary Alex Azar has this pen. It’s not all that remarkable looking, but he held it up multiple times Monday at a briefing with reporters.

“This pen,” he said, “has a lot of power.”

And he said he is prepared to use it.

Azar was making the point that in the area of drug prices, the head of HHS — which runs the Medicare and Medicaid programs and buys about $130 billion in prescription drugs each year — can make a lot of changes in the pharmaceutical market. And he doesn’t need congressional approval to do it.

He’s got plans to use that pen to change the way Medicare and Medicaid pay for medications and how the Food and Drug Administration goes about approving drugs for marketing.

Lots of the ideas are wonky and esoteric, but analysts say some could make a big difference over the long term.

Here are three of the big ideas Azar laid out Monday, three days after President Trump unveiled a blueprint to lower the cost of prescription drugs that was criticized for being light on substance.

1. Restructure the way pharmacy benefit managers deal with drugmakers

Azar’s most ambitious initiative would ban pharmacy benefit managers — the companies that administer prescription drug plans for insurance companies or employers – from negotiating discounts with drugmakers as a percentage of list prices.

Today PBMs, such as CVS Caremark or Express Scripts, make deals in the form of rebates. Pharmaceutical companies offer something like 30 percent off the list price of their drugs if the PBM places the medicines in a favorable spot on their preferred drug lists. When prices go up, PBMs often make more money as rebates grow.

“They’re taking money from both sides,” Azar said. “They’ve built into their system a regime where they get more money when the list price goes up.”

Azar said he intends to force PBMs to write contracts based on a set price for drugs, rather than a percentage-based rebate. And, he said, he’s looking to ban them from making any money at all from pharmaceutical companies. Instead, the companies would earn money only from the fees paid by the insurance companies or employers who hire them.

“This is nothing short of the complete and fundamental restructuring of over $400 billion of the U.S. economy,” he said.

David Mitchell, founder of the advocacy group Patients for Affordable Drugs, approves of the idea. “If they could do away with the rebates and have transparent net prices, I think that’s an enormous step forward,” he said.

But Express Scripts spokesman Brian Henry takes issue with targeting PBMs. “The root cause is the pharmaceutical companies who set these prices,” he said. “We are the ones who help drive down the costs. We drive competition.”

2. Change the way Medicare pays for some expensive drugs

Azar says he wants to simplify the way Medicare pays for many drugs by moving some expensive medications that are administered in doctors’ offices — like cancer drugs — into the standard Medicare prescription drug program.

Many of those expensive drugs are paid for through Medicare Part B. It’s a system in which doctors buy the drugs and get paid a percentage of their cost to administer them to patients. Under this system, the government pays the full list price and doctors make more money when they prescribe more expensive drugs.

Azar said he wants to move some of the most expensive of those drugs to the Part D program, which is administered by private health insurance companies that negotiate discounts with drug companies.

“This move from B to D gives us the power to negotiate against drug companies,” he said.

But analysts caution it could lead to higher out-of-pocket costs and less choice for patients.

“Moving drugs from Part B to Part D could get the prices of some drugs down by allowing insurers to bargain with drugmakers, but it would likely come with more restrictions on which drugs are covered,” said Larry Levitt, vice president of the Kaiser Family Foundation. “Some Part B drugs — many of which are infusions like chemotherapy — don’t have competitors, so negotiation may not help much.”

3. Make prices more transparent

The Centers for Medicare and Medicaid Services will release new versions of its Medicare and Medicaid drug price dashboards on Tuesday that HHS says will have more detail on how much the programs are paying for the medications they buy.

And on top of that, Azar says he is looking at whether he can require drug companies to include the price of their products in those television ads that already include seemingly endless lists of scary side effects.

Mitchell and Levitt both doubt that drug companies can be shamed into lowering prices and losing profit.

“It’s not going to lower drug prices,” Mitchell says. “But it would probably help for patients to know that the drug they’re getting costs $100,000.”

And finally, he wants to get rid of what he calls a “gag rule” in some PBM contracts that forbid pharmacists to tell patients they can get their drug cheaper by going outside their insurance plan.

“Note that there are a number of proposals they are suggesting that are controversial and will result in pitched battles,” says Rodney Whitlock, vice president of health policy at ML Strategies, a lobbying firm. “That said, they sure are talking a good game and should be given deference that action will approach rhetoric.”

Azar, who came to HHS after a stint as president of the U.S. operations of the pharmaceutical giant Eli Lilly, opened his talk by dispensing with the industry’s long-embraced argument that high prices are necessary to pay for research into future cures.

“I’ve been a drug company executive. I know the tired talking points: the idea that if one penny disappears from pharma profit margins, American innovation will grind to a halt,” Azar said. “I’m not interested in hearing those talking points anymore.”

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