Celebrity suicides by people who seemed to have everything have reminded us that depression and suicidal impulses can be as lethal as any physical disease.

"The suicide rate in the US has risen by 22 percent since 2000. While the prevalence of depression overall remains steady, there are great geographic differences. At 12 percent, the depression rate in Alabama is double the national average. Suicide rates are also significantly higher," UAB professor of psychiatry Richard Shelton, MD said.

The dramatic increase in suicides over the past two decades goes well beyond those who were known for fame and fortune. Recent news has brought stories about epidemics of suicide among New York taxi drivers who can't cover their expenses; farmers and ranchers who have lost everything; unemployed factory workers; and soldiers returned from war.

The new faces of suicide include far more women than in the past, and more people in their middle years who could no longer see other options to escape their pain.

It's happening everywhere in the US, but why is it happening here more often?

"It's a perfect storm for depression," Shelton said. "Alabama is a rural state where social isolation and lack of access to mental health services are a double burden. There is so much entrenched poverty, yet few people qualify for mental health services under Medicaid. People with jobs and insurance may also find it difficult to fit mental health services in between family budgets and the limited mental health reimbursement benefits offered by many health plans.

"Even those with resources may find themselves waiting for an appointment. Alabama has fewer mental health providers than any other state in the nation.

"Another major risk factor for depression is poor physical health. Alabama's high rates of obesity, metabolic health disorders and the health problems that come with them add to the risk."

DeLisa West, PhD, of West Neuropsychology said, "There is also still a stigma and a reluctance to ask for help."

A common problem is the cultural stereotype that men stoically deal with their problems and women should be steel magnolias who can handle anything. Some fear that people would see them differently if they knew, or trust them less in ways that could affect their career.

"We need to change attitudes and normalize mental health services so seeking treatment is as accepted a part of staying healthy as making an appointment with an internist," West said.

Another factor in higher suicide rates results from having the means to commit suicide readily available when the impulse strikes. States where suicide rates are highest also correlate with the highest percentage of guns in the home. Suicide attempts using guns tend to be more successful. There is no lag time for someone to call 911, and no second chances to get the supportive help they need.

The roots of depression are no longer seen in simple terms of a biochemical or situational reaction, but as a more intricate combination of factors that vary by case and are influenced by prior experiences.

"Depression tends to be triggered by a stressor. However, many people can experience the same event and react very differently," Shelton said. "Most people who experience a loss don't develop serious long term depression, just as most soldiers who return from war don't develop PTSD.

"There is a 'double hit' hypothesis that people who experience a serious loss or trauma, abuse or bullying earlier in life may be more vulnerable to responding to future stressors with depression."

In treating suicidal depression, researchers at UAB have been making progress using ketamine, and have developed a ketamine nasal spray that is expected to be approved by the FDA within the coming year.

Before treatment can work, however, depression and suicidal ideation have to be identified. The lack of access to mental health services puts healthcare providers on the front lines in identifying patients who need help.

"With every health care encounter, we need to look at the patient's emotional health and ask the questions," Shelton said.

Any new stresses at home or work? Anything on your mind lately that has been difficult? If there are indications that suggest depression, ask the next question: have you had thoughts that life may not be worth the effort?

"It's a difficult conversation to bring up," West said. "People have to feel safe talking with you. When you ask the question, you need to be ready for the answer. A patient may not have the resources for private mental health services, but they need to know that help is available. They do have better options to deal with the pain. You need to be ready to refer them to agencies, crisis lines, and online help."

Those who heal the body can also save lives by listening.