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

FARGO — In Dr. Julie Blehm's home in south Fargo, the memories of her husband, David, are still present.

Art pieces the two collected together hang on the walls. The table where he kept piles of books still sits in the dining room.

To her, Dr. David Blehm was the most interesting man she had met. She didn’t see any sign her pediatrician husband was so unhappy that he would end his life.

“I never thought he was suicidal,” she said. “I just never had that feeling.”

While on a business trip, David Blehm’s employer called and told her he did not show up for work. She later learned that he took his own life on Nov. 7, 2011. He was 59.

“I think, so many people respected you as a pediatrician and appreciated the reading lists you gave to their children and all these different things. How could you have been so unhappy that you did this?” she asked.

Middle-aged white men, like David Blehm, have the highest rate of suicide among any group in the U.S., according to the American Foundation for Suicide Prevention. In 2017, white men made up almost 70% of suicide deaths in the U.S., and middle-aged groups rise to the top when it comes to rates, the organization said.

Working-aged men make up the largest portion of suicide fatalities in North Dakota, said Alison Traynor, North Dakota's suicide prevention director. In Minnesota, middle-aged men also are at an increased risk, according to the Minnesota Department of Health.

White men in the U.S. have a culture of being the breadwinners and protectors of their families, said Dr. Liza Tupa, a clinical psychologist who's studied suicide. They also are taught to “pull themselves up by their bootstraps” instead of seeking help, said Tupa, education and research director for the Western Interstate Commission for Higher Education (WICHE) in Boulder, Colo.

Julie Blehm asked her husband to seek help after she noticed he was drinking more in the years leading up to his death, but he said he could deal with it by himself.

After his death, she talked with her son, who said he realized his father probably felt he may have failed at some things in his life, she said. “Here he was middle-aged ... kind of nearing the end of his career and thinking, ‘I really didn't do as well with all of this as I thought I would,’” she said.

Julie Blehm, a physician who specializes in caring for the elderly, has told her husband’s story to educate medical professionals, and she's played a role in initiating changes in North Dakota to encourage doctors to get the treatment they need.

“It doesn’t mean you’re an awful person. It doesn’t mean you’re weak. It means that you have an illness,” she said. “I think that is the most important thing.”

Other stories in this series:

• Suicide numbers keep rising in ND and Minn., but there's help and hope

• This North Dakota soldier reached the brink of suicide, now he's spreading his message to other vets

• LGBTQ people are more likely to attempt suicide, but one friend can make the difference

• Faced with trauma, focused on the future: Tribes fighting to curb rising Indigenous suicide rates

The numbers 'woke us up'

North Dakota and Minnesota do not specifically track suicide rates for middle-aged white men, but both states monitor trends by race, gender and age.

White people made up 85% of the deaths by suicide in 2018 in North Dakota. The same year, the suicide rate for whites in North Dakota was 20 per 100,000, according to the state Health Department. That’s above the national rate of almost 16 per 100,000, according to the Centers for Disease Control and Prevention.

Whites in Minnesota accounted for 91% of suicides in 2017, the latest figure from the state's Department of Health. Suicide rates by year were not available, but the rate for 2013-2017 among whites in Minnesota was 13.4 per 100,000, second only to American Indians with 23.2.

Since 2000, the rate of men taking their own lives has remained higher compared with women in North Dakota and Minnesota. Men were four times more likely to kill themselves compared with women, according to data from both states.

“I think that the numbers that came from North Dakota ... I think they woke us up as a state,” said Thomasine Heitkamp, project co-director and principal investigator for Mountain Plains Mental Health Technology Transfer Center in Grand Forks. “I think that we started to dig a little deeper into the causes.”

Middle-aged white men are exposed to various risk factors, such as economic stress, chronic health conditions and the pressures of succeeding, Tupa said. A lack of access to treatment, especially in rural areas, also is troubling, experts said.

“How do you turn reaching out for help into a strength?" Tupa said. "That's the message I think that we have to give everyone, but especially ... to this group."

How to raise awareness

To solve the complex issue of suicide, everyone needs to come together to remove barriers to treatment, provide suicide prevention training and expand communities’ abilities to discuss the topic, experts told The Forum.

With guns contributing to 50% of suicides in the U.S., there should be more discussion of what measures can be taken to keep guns away from people who have suicidal thoughts, said Gina Brimner, director of veterans initiatives for WICHE.

David Blehm shot himself with a gun he owned, and his wife agreed there needs to be more education about firearms and suicide prevention. "It's a difficult conversation in many states because it gets confused with gun control," Brimner said, but those conversations could save a life.

Media campaigns can help bring awareness, Heitkamp said. She mentioned outreach efforts at grain elevators, churches and other places where men in rural America go.

North Dakota State University Extension Service partnered with Lutheran Social Services to make an educational handout for farmers and ranchers. The wallet-sized card is called "bootstraps," and it features a pair of worn boots with information about depression, the people it affects and what to do to get help.

“We’ve actually used that bootstraps mentality as a way to reach people,” said Sean Brotherson, an extension family science specialist at NDSU.

Research shows working in agriculture is one of the most stressful occupations. Uncontrollable factors can decide the success of a farmer or rancher, and that's compounded by exhausting work, long hours, financial stresses and isolation, Brotherson said.

Farmers are raised in a culture of dealing with issues privately and minimizing the severity of health concerns, Brotherson said. But he has been encouraged recently as more people are recognizing that mental health concerns are common and that they are treatable if a person seeks help.

'Man Therapy'

“Did you know that men have feelings, too?” a mustachioed man asks while sitting in an office that looks like a cross between an attorney’s office and a man cave. “And no, not just the hippies. All of us! Hello, I’m Dr. Rich Mahogany. Welcome to Man Therapy.”

The fictional doctor is the star of mantherapy.org , a website created by the Colorado Department of Public Health and Environment with the aim of helping men address mental illness. The website has statistics, testimonials, tools to assess mental health and a little bit of edgy humor.

“What the initial research showed is that there was a need for a different type of messaging that was more engaging with men, and it was scrubbed of some of that sterile, traditional mental health jargon,” said Sarah Brummett, Colorado's suicide prevention director. “It needed to resonate with men a little bit differently.”

Men now have an anonymous place to seek information, and the website shows "manly men" who have struggled with mental health. "It highlights that having a mental health challenge doesn’t mean you’re less of a man," she said.

The website has had almost a million visitors since its launch in 2012, Brummett said. Man Therapy could reach more people if there was more funding to promote it, but it has received great feedback, she said.

Colorado's overall suicide rate in 2017, the latest year available, was roughly the same as it was in 2012 — about 20 suicides per 100,000 people. While the number hasn’t gone up, officials there say a collaborative effort is needed to drive the rate down.

Man Therapy is a fantastic program, Traynor said. But North Dakota’s data shows suicide doesn’t discriminate, she said.

North Dakota's suicide prevention program was moved from the state Department of Health to the Behavioral Health Division in July, meaning staff are building “a lot of things from the ground up,” Traynor said. The state is starting to create the foundation for intervention services, she added.

“With our limited resources, what we're trying to do is address factors that really impact all populations,” she said.

'You did the best you can'

Just hours before Julie Blehm spoke with The Forum at her home, she sat at a conference room table in Sanford Medical Center, hosting a seminar on provider depression and suicide with the University of North Dakota School of Medicine and Health Sciences.

She shared her husband’s story — his struggle with alcohol, the idea that he didn’t want to admit he couldn’t handle his problems by himself, the guilt and anger that came with his death and how she came to accept it all.

“I have to talk about him," she said. "We can’t avoid this subject forever."

With help from a psychologist and an American Foundation for Suicide Prevention support group, she was able to express her anger at her late husband, that she hated him when he drank — without judgment. She now serves as a board member for the AFSP North Dakota chapter.

Statistics show that physicians are at a greater risk of suicide than the general public. Thanks to Julie Blehm and others, doctors now don’t have to report to the state licensing board that they are struggling with mental illness or substance abuse if they voluntarily seek help through the North Dakota Professional Health Program.

She said multiple factors likely played into her husband’s death, but maybe the reporting change would have saved him.

People who have lost someone to suicide will likely feel a range of emotions, and they may wonder what they could have done differently to prevent it, Julie Blehm said.

Those people are not alone, she emphasized.

“A final thought is, for people who are survivors of someone who has killed themselves that they cared for and love, I think you did the best you can,” she said. “Remember, you tried. You did the best you were able to do at the time, and it is not your fault.”