DES MOINES, Iowa -- Mary Elliott got the call for help on a Monday night. A "suicidal male teen" was at a convenience store, not far from his high school.
When she arrived, Elliott - a nurse on Des Moines' crisis response team - found the young man still dressed in the suit he'd worn that day to the funeral of another teen who'd killed himself. He was relatively calm and, at first, denied he was considering suicide.
But by the end of the night, he told Elliott even more than she'd anticipated: He wasn't the only one who felt like ending his life. And while he did so reluctantly, he gave her names of eight other teens from his high school who also talked about suicide - and, in some cases, even said how they'd do it.
"All of this is too much for a kid to handle," she remembers him repeating several times that night.
In the days that followed, media reports referred to a suicide "pact." But those who eventually spoke with the other young people said there was never anything written or signed.
It was, they say, a loose verbal agreement - "I'll do it if you do it" - that some of the teens seemed to take more seriously than others.
Whatever the case, the events of that night left many in Des Moines shaken - and have since prompted discussions about how to best deal with a problem that plagues communities nationwide. In Iowa, suicide is the second leading cause of death for those age 15 to 24, after car crashes. Nationally, it ranks third for that age group.
"These kids don't understand, really, that suicide is final - and that prom will go on without them, the football game will go on. Life will go on without them," says Dave Spieker, another crisis response nurse who was on duty that October night.
As the midnight hour approached, both he and Elliott met with school officials to pore over registration records and yearbooks to come up with a more complete list of names and addresses.
The details they'd been given were sketchy. They knew all the students attended Lincoln High School. But often, the young man gave only first names. And in one case, he couldn't remember a girl's name - only that she had "red hair."
Still, the crisis team and school officials knew they had to act quickly.
It had already been a rough fall for the 2,100-some students at Lincoln High, a stately red brick building surrounded by oak trees in a neighborhood of modest homes.
In September, three male students died in a single car crash, leaving the young driver - the lone survivor - charged with vehicular homicide.
Not long after, 15-year-old Billy Metzger hanged himself in his bedroom closet.
Surviving students mourned together, writing "RIP," "RIP," "RIP," "RIP" in chalk on many of the school's bricks. Another scribbled, "Damn, Billy, we're going to miss you" on the sidewalk.
"Most people are doing OK now. But not a day goes by when we don't think about what happened - even if we didn't know the guys who died very well," Josh Rector, a senior at Lincoln High, said recently.
Immediately after Billy's death, some students cried and huddled together in groups in the hallways. Still others kept to themselves, stunned and silent.
School officials did their best to deal with the extreme grief. They offered counseling for anyone who asked and, fearing copycat suicides, asked teachers to watch for students who were struggling emotionally.
Still, some wondered whether the school could have much impact since Billy's suicide had happened on a Thursday.
On Friday, Oct. 2, students heard the news and gathered that night for a football game. Then they dispersed for the weekend, with Billy's funeral scheduled the following Monday.
"It's up to the community and the parents now," said Jerry Clutts, a school official who helped devise the district's crisis response plan.
It was during that weekend, crisis officials say, that the nine students spent hours talking and grieving together - at times so sad that they, too, considered suicide.
Dave Smith, a Des Moines police officer posted at Lincoln High, is among those who doesn't think those discussions resulted in a "true pact."
"You just had some kids who were pretty volatile at the time," he says, adding that they are "good kids, for the most part."
Crisis workers also determined that some of the teens had been struggling well before the deaths of their four classmates.
One had issues at home and was living in a youth shelter. Another had attempted suicide in the past. And at least one more had been treated for depression.
By 5 a.m. the morning after Billy's funeral, authorities had contacted all the students and their parents. Some students were clearly confused, and said they knew nothing about it. A few parents were angry. But still others said they, too, had been concerned about their children.
Eventually, four of the nine teens were hospitalized.
"As far as I'm concerned, it was worth it to me to get up out of bed to check on them," says Officer Smith, who visited some students' homes with Elliott that night. "We're better safe than sorry."
Now, more than two months later, things have quieted down at Lincoln High. Billy Metzger has been laid to rest in a small cemetery surrounded by corn fields - his grave's temporary marker covered with a silver chain with a cross on it and a warm fleece hat.
And all but one of the nine students have returned to school. (Officials have declined to release their names due to the sensitivity of the matter.)
Counseling has remained available to students in need. But almost immediately, the school's principal removed a makeshift shrine placed on Billy's locker.
Experts say that's as it should be.
"It's difficult. But you don't want to see anything that glorifies or sensationalizes it," says Dr. Kevin Took, a child and adolescent psychiatrist at Blank Children's Hospital in Des Moines.
Still, he and other experts say that it is important to talk about suicide, which many see as a serious public health issue.
Research shows, for instance, that one in four teenage girls and one in six teen boys have had serious thoughts about suicide. Many who kill themselves or attempt to do so have psychiatric problems.
"We've spent more time educating the public about West Nile virus than we have suicide," says Larry Hejtmanek, head of the Eyerly-Ball Mobile Crisis Response Team, which led the effort after Billy's funeral. "People think everything's fine, until the next crisis."
He notes that many states have begun implementing federally funded suicide prevention programs. And some schools are taking steps of their own.
Des Moines school officials are now considering using a test developed at Columbia University called Teen Screen to pinpoint students with mental health issues. The test, they say, could be given as routinely as hearing and vision screenings.
Meanwhile, a few hours east in Camanche, Iowa, students can anonymously submit the name of someone they're worried about using yellow cards and a box placed in a high school hallway. The idea, started after two Camanche teens committed suicide, came from the nonprofit Yellow Ribbon Suicide Prevention Program.
Some young people in Des Moines say recent events might prompt them to tell an adult if a friend seemed suicidal.
"If it's a really serious thing, it is important to tell somebody," says Jadie VanPelt, a freshman at Lincoln High. "But first I would try my best to convince them not to do it."
Still others, including 19-year-old Lindsey Mason, say it would help if adults - especially parents - felt more comfortable talking about suicide.
"It's a hush-hush topic," Mason says. "And it shouldn't be."
A list of suicide warning signs
Suicide is the third leading cause of death for Americans age 15 to 24 (behind car crashes and firearm homicides) and the second leading cause of death for college students.
The American Foundation for Suicide Prevention has detailed a few "signs of crisis" that might indicate someone is contemplating suicide:
- A recent precipitating event that has been particularly distressing, such as the loss of a loved one or a career failure;
- Depression and intense anguish with an urgent need for relief that expresses itself as rage, anxiety, guilt, hopelessness and/or an acute sense of abandonment;
- Changes in behavior;
- Direct or indirect talk suggesting that the person is contemplating suicide. Sometimes it sounds as if the person is saying goodbye or going away. Or the person might say something like "My family would be better off without me";
- Actions ranging from buying a gun to putting one's affairs in order;
- Deteriorating function at work, school or in social settings; increasing use of alcohol or other self-destructive behavior.
On the Net:
Suicide Prevention Resource Center: http://www.sprc.org
Yellow Ribbon Suicide Prevention Program: http://www.yellowribbon.org/