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Teenage Girl

If More Treatment Is the Answer, Why Haven’t the Numbers Gone Down? 

As suicide numbers increase, we continue to hear suggestions that “undertreatment” is the main problem. After two decades of rising treatment rates, could it be time to reassess?

Just this week, a friend called to tell me he was on the way to a hospital to visit his daughter who had attempted to take her life. A few weeks ago, another friend confided his niece had made the same heartbreaking attempt. A month before that, a beautiful young man in our community took his life. And a short while before that, another close friend anguished over suicidal thoughts her daughter was having. 

What’s going on? And what more can be done? 

These are questions that unite all of us. They have been on the minds and hearts of everyone who has been touched by these painful situations (which includes, by now, most all of us). 

Let’s also be clear: everyone’s doing what they can—and helping however they know best to reduce these numbers. That’s not in question and never should be. 

But it’s not enough. We all know that. The stories and numbers continue—and at historic levels.

Could it be time to pause this urgent conversation long enough to reassess some of our fundamental starting points?

How the conversation usually goes

Last month, I sat in a suicide prevention presentation in my home state of Utah where the speaker closed his remarks underscoring a central need to “get more teens access to treatment.” This same sentiment is often heard from academic psychiatrists and community leaders speaking about the mental health crisis. Just last week, Dr. Friedman suggested in a recent New York Times op-ed (featured prominently in our own local paper) that presumed inaction in the face of the American suicide crisis was lamentable since (1) “we know perfectly well how to treat this illness,” and therefore (2) we don’t have to wait for all the answers to know what to do.”

The solutions, from this vantage point, are plain and obvious. And if only we would do a better job of getting those solutions to more youth, this doctor went on to argue, the numbers would go down. Why can’t we muscle up the will to follow this clear path forward?  

Oh, Doctor Friedman, but we already have! For twenty years now, Americans have been focused (and encouraged to focus) on reducing stigma and helping more people overcome hurdles to accepting treatment.  It was in 2001 that Eli Lilly scientists Gary Tollerson argued at an FDA hearing, “It is our feeling that the major public health concern relative to suicidality and depression is the current stigma, under-recognition and undertreatment of a very serious disease.”

Since then, organizations like the National Alliance on Mental Illness have been advancing the same essential argument, with our own director of Utah NAMI Utah suggesting in 2007 that the “elephant in the room” was “untreated or undertreated mental illness.”

That line of thinking has rippled out over op-eds, community presentations, and public discussion a million times over.

And it worked. These calls have not gone unheeded. A 2011 report released by the National Center for Health Statistics (NCHS) showed that the rate of antidepressant use in the U.S. among teens and adults (people ages 12 and older) had increased by almost 400% between 1988–1994 and 2005–2008—with estimates of one in every 10 Americans now taking an antidepressant. A more recent 2016 analysis looking at prescribing trends between 2005 and 2012 in the U.S and Europe found that “antidepressant treatment in children and adolescents has increased substantially in youth cohorts from five Western countries.”

Of course, medical treatment is only one of many kinds of interventions—and providing some kind of immediate support is crucial in situations like this.  And there are a variety of other noteworthy approaches communities have experimented with over recent years worthy of further consideration. None, however, has had any comparable expansion of usage comparable to SSRI antidepressant treatment. During this same period, for instance, rates of psychotherapy support for youth (or adults) have not increased in corresponding fashion—with analyses more often than not finding a decline in counseling rates over recent years.  

Practically speaking, then, although legitimate calls could be made for more treatment access to a wide variety of psychosocial supports, it only appears to be the expanded embrace of SSRI antidepressants among both youth and adults that follows the many (and continuing) calls for “more treatment access” and concerns with “undertreatment.” In their meeting at the hospital, this is exactly what my friend was advised her teenage daughter would urgently need.

All of this begs the obvious, but little acknowledged, question: If getting teens (and adults) more medical support was really the perfectly clear answer (and if those treatment rates have risen as steeply as they have), wouldn’t we have reasonably seen a measurable decrease in suicide, depression, and anxiety by now? 

The question we have to talk about – even if it’s hard.

That’s the question I asked at the end of the suicide prevention presentation emphasizing a need for increased treatment. During the Q/A, I raised my hand and asked, “Haven’t we been doing that effectively for the last two decades—increasing treatment rates across the nation? If so, is there more we should be thinking about right now if we are serious about reducing these numbers?”

That’s the same question I would sincerely raise to medical doctors and community leaders around the country. As is painfully clear to all of us, despite these kinds of substantial increases in access to psychiatric care, there is a great deal of evidence that the burden of mental/emotional distress has increased markedly during the last two decades. Why?

If getting teens more medical support was really the answer, wouldn’t we have reasonably seen a measurable decrease in suicide, depression, and anxiety by now? 

No doubt, this partly has to do with many shifting factors in the socio-cultural milieu around us. Many studies have now linked economic distress and air pollution to higher levels of depression and anxiety. And there is compelling evidence to suggest that the ongoing digital revolution around us, especially via social media, has been especially hard on our youth. In my work helping support teens and adults seeking longer-term freedom from pornography use, the level of despair youth and adults feel who continue to see relationships and dreams burdened by these addictive patterns is remarkably intense. Other factors like abuse, family dissolution, sexual assault, poor diet, sleep deprivation, and social disconnection leading to historic levels of loneliness also clearly weigh on people.

With most (even all) of these factors increasing in intensity over recent decades, they also must be seriously considered as part of what influences the rising suicide, depression, and anxiety numbers.  No single factor is responsible, and clearly the question is complex.  After examining cases of suicide in our own state, one suicide research team summarized, “Our investigation showed that suicide is complex and youth can experience multiple risk and protective factors. No single behavior or risk factor could explain all the reasons for the increase we’ve seen.”

Precisely because of this complexity, the need for multi-faceted, whole-life intervention focus seems evident.  But that’s not what these calls for “more treatment” are leading youth and adults towards…it’s just not.    

In some cases, of course, immediate medical support may be exactly what a teenager or adult needs. In other cases – for complicated reasons deserving more attention – this may not be helpful, and could potentially aggravate the situation – or distract an individual or family from other supports.  Indeed, many youth and adults who end up taking their lives have been in treatment. In an analysis of “precipitating circumstances for [teenage] suicide decedents” in Utah, it was found that “of those with diagnosed mental health problems, 84% were noted to be receiving mental health treatment at the time of death.”

If we’re serious about doing everything we can to reduce suicide, this must include a show of greater willingness to acknowledge that some of our attempts to do good may have inadvertent consequences. Since an in-depth study of antidepressants I conducted in 2007, I’ve continued to follow the research and read many cases involving unexpected, uncharacteristic, sudden suicidality occurring when someone started medical treatment.

In a time when troubling numbers have reached such historic levels, one would think it was time to reassess and reevaluate a lot of things—from the way we conceptualize these problems, to what we’re doing about them (and what we’re not doing about them).

Instead of this kind of pause for reflection, however, all across America what we mostly see today is a doubling down of the medication-centric approach we’ve taken for the last twenty years. My own attempts to invite a bigger conversation with doctors, fellow psychologists, and community leaders have been met with remarkable resistance and outright skepticism.

For many, the idea that taking an antidepressant could worsen your mood and invoke suicidal thoughts or feelings seems ridiculous—after all, they’re antidepressants, right? 

To any who see these concerning possibilities as somehow ‘out there’ or hard to believe, it helps to remember that suicide warnings are on the package! Rather than some outlier idea, these are risks acknowledged on every package of antidepressants, ever since the black box warning was mandated following FDA hearings and a comprehensive review of the evidence.

Given how unaware most people are of the actual evidence behind these cautions, however, I summarize below four general lines of evidence from a more comprehensive review last year on suicidality and antidepressants.

Importantly, the information that follows does not constitute medical advicenor does it replace any guidance received from professional helpers, whether that is a therapist or doctor. Antidepressants have been helpful for many people. And under no circumstances should someone stop taking medications quickly or without appropriate supervision. That can be dangerousso please only take steps carefully, gradually with the support of trusted people around you.

If you feel suicidal, please reach out to a loved one or trusted professional. And if you have no one to talk with, please contact a prevention line available in your country. For instance, the National Suicide Prevention Lifeline in the U.S. can be reached 24 hours every day here: 1-800-273-8255. And here is a list of other suicide prevention hotlines available in countries all around the world.

These four lines of evidence are shared in hopes of helping expand the professional and public conversation about suicide – specifically, clarifying the empirical basis for taking this possible risk seriously as a way to take additional steps in preventing this tragedy for many more people.

1. Professional & Personal Accounts

From the earliest moment that Prozac came to market, concerns were documented by some clinicians. For instance, one respected researcher, Martin Teicher, wrote in a 1990 case study: “Six depressed patients free of recent serious suicidal ideation developed intense, violent, suicidal preoccupation after 2-7 weeks of fluoxetine [Prozac] treatment. This state persisted for as little as 3 days to as long as 3 months after discontinuation of fluoxetine [Prozac]. None of these patients had ever experienced a similar state during treatment with any other psychotropic drug” (emphasis added).

A few years later, Teicher and colleagues reported on one young girl who began cutting herself after taking a high dose of Prozac, with self-mutilation described as “incessant.” And yet, after this patient tapered off Prozac, her self-destructive behavior and suicidal thoughts disappeared.

As other similar case studies like this emerged, a pattern became evident, as Dr. Teicher himself summarized at a follow-up FDA hearing: “The reason why I believed that we were dealing with a drug-emergent effect is because the symptomatology that [patients] developed during the time they were on fluoxetine was unlike anything they had experienced prior to or following.”

Similar observations have emerged from family members, friends, neighbors, and journalists as they grappled to make sense of a tragedy after the factaggregated in various online repositories. For instance, one father wrote: 

In 2009 my son, who had never been depressed in his life, went to see a doctor over insomnia caused by temporary work-related stress. He was prescribed Citalopram [Celexa], and within days he had taken his life. At my son’s inquest, the coroner rejected a suicide verdict, but delivered a narrative judgment, citing Citalopram by name as the “possible cause.”

Unfortunately, these kinds of personal accounts have been written off frequently as “just anecdotal” (a.k.a, not worth much). I disagree. Even one story ought to mattereven if it, admittedly, cannot provide definitive answers. And when many stories start to establish similar themes (1,000 have been gathered in one online database), we ought to be paying careful attention. After spending hours analyzing these kinds of stories across various online archives, three patterns stood out:

  • First, in many cases the suicidal behavior that emerged in these narrative accounts was completely out of character for people who were otherwise reported by family to be moving forward with generally productive, successful lives. Often, these individuals had simply reached out to a physician during a challenging timefor instance, involving unusually high stress.
  • Secondly, when a marked psychological deterioration started to occur after starting treatment, neither the surrounding families and friends nor the person taking the medication had any idea it might be connected to treatment. Perhaps due to the emotional pain already present, the idea that additional distress could be drug-induced hardly seemed on the radar.  It was common to hear from family afterwards, “I had no idea that this could be a possible side-effectnot at all.”
  • Third, when early problems started to emerge with the antidepressants, the professional response typically involved (a) encouraging people to increase the dosage and (b) attributing new emotional distress (like new panic attacks) as reflecting underlying pathology being newly discovered—“now we know you have an anxiety problem as well” or “psychosis might be something we need to pay attention to.” It seems clear from most stories that even medical professionals have remarkably little awareness of the possibility of antidepressantinduced suicidality. Many don’t seem to have ever been seriously educated about this as a possible risk.    

2. Established Side-Effect Profiles

Compared with a remarkable lack of awareness regarding possible drug-induced suicidality, there is more general awareness about varied side-effects that can arise when starting a psychiatric medication. Three more common examples have particular relevance to the discussion around suicide.

a. Akathisia. This is a fancy word for “inner restlessness.” On the original patent for Prozac, akathisia was labeled as “one of its more significant side effects.” Neuro-psychologist Dennis Staker describes his own drug-induced akathisia during two days as “the worst feeling I have ever had in my entire life. I wouldn’t wish it on my worst enemy.” Another individual characterized it as “ach[ing] with restlessness, so you feel you have to walk, to pace. And then as soon as you start pacing, the opposite occurs to you; you must sit and rest. Back and forth, up and down you go . . . you cannot get relief.”

In another case study, Rothschild and colleagues note: “Three patients developed severe akathisia during retreatment with fluoxetine [Prozac] and stated that the development of the akathisia made them feel suicidal and that it had precipitated their prior suicide attempts. The akathisia and suicidal thinking abated upon the discontinuation of the fluoxetine.”

b. Amotivation/Apathy. Dr. Jane Garland and colleagues report five cases of youth prescribed antidepressants who came to experience a unique level of apathy and lack of motivation. In each case, these symptoms were linked directly to dosage and were reversible after tapering back the medication. However, given (a) the similarity to depression’s own symptoms, (b) a child’s lack of insight in appreciating this, and (c) the fact that the onset of this lack of motivation comes later on in treatment, Dr. Garland warned about the strong likelihood of missing this possible adverse effect and the need for carefully monitoring children especially. This phenomenon of drug-induced amotivation/apathy has also been studied and documented over the years in adults taking antidepressants as well, with 11 different studies from 1990 to 2016 referenced in the longer analysis.

c. Hyper-Activation/Disinhibition. Compared to the decreasing motivation just described, a seemingly opposite agitating effect has been noted by researchers for years (see 2004 FDA report here). In 2003, Faeda and colleagues wrote about “treatment-emergent mania (TEM) or increased mood-cycling following pharmacological treatment” in youth, a subset of which experience “prominent suicidal behavior.”

And in 2006, Goodman and colleagues investigated one of the mechanisms behind suicidal behavior leading to the black box warning, noting that “during the course of SSRI treatment, some children may experience an ‘activation syndrome’ characterized by agitation, insomnia, irritability, brittle mood, and other signs of hyperarousal that, if unrecognized, could conceivably foster suicidality.”

Even one story ought to mattereven if it, admittedly, cannot provide definitive answers.

Dr. Shauna Reinblatt and colleagues summarized their data in 2009 documenting the frequency of this concerning pattern of “activation” involving specifically impulsivity, insomnia, or disinhibition. Compared to 23 youth in the placebo group (where 1 experienced symptoms of restlessness), 10 of the 22 youth (45%) in the treatment group experienced this kind of heightened activity. Other studies have found between 10 and 50% of kids experiencing these same abnormal “activation” symptoms. On average, these symptoms emerged anywhere between week 1 and week 8 (with week 4 being the average).

Whereas some have attributed these manic episodes to a latent bipolar disorder, other case studies confirm the frequency of this occurring as a drug-induced effect. For instance, Dr. Aggarwal reported in 2011 on a boy (without any present risk factors for bipolar patterns) who experienced “increased psychomotor activity, euphoric affect, racing thoughts, grandiose ideas, and inflated self-esteem” upon starting an antidepressant. Once the prescription was ended, these symptoms went away.

It’s one thing to consider personal accounts or side-effect profiles, but what do the actual peer-reviewed studies say?

3. Observational/Correlational Evidence

There are at least four major correlational/observational studies within the last decade and a half looking directly at this question. One 2006 study led by Dr. Olfson in the Department of Psychiatry at Columbia University compared Medicaid beneficiaries across the country who had similar patient profiles, except for differences in whether they received antidepressant treatment or not. While no significant differences were found in adult suicide attempts or death, they noted, “In children and adolescents (aged 6-18 years), antidepressant drug treatment was significantly associated with suicide attempts and suicide deaths.” 

More recently, Umetsu and colleagues reported in 2015 on a large epidemiological study based on data from the Food and Drug Administration (FDA) Adverse Event Reporting System database, with analyses confirming clear associations between SSRI treatment and suicidal and self-harm events, especially in the under 18 group (less so for older participants). In a 2016 observational study of 392,458 Danish medical records, Christiansen and colleagues likewise found “a significant overlap between redeeming a prescription on SSRIs and subsequent suicide attempt.” The researchers noted, specifically, that “the risk for suicide attempt was highest in the first 3 months after redeeming the first prescription.” 

Finally, a 2017 study analyzed 483 suicides of young women in Sweden between 1999-2013 (representing 93% of all confirmed suicides for this subgroup)with a focus on looking at whether these women had received antidepressants within 6 and 12 months before the suicide. Dr. Larsson summarizes what she found: “The previous assumptions that treatment with antidepressants would lead to a drastic reduction in suicide rates are incorrect for the population of young women. On the contrary, it was found that an increasing tendency of completed suicides follow the increased prescription of antidepressants”reflected in a “covariance between increased prescription of antidepressants and an increasing trend in the number of suicides among young women.” 

In fairness, correlation studies can still only tell us so much. Similar correlation designs have been associated in recent years with dubious claims that an increase in pornography yields an associated decrease in rapeor that percentages of certain religious denominations in a given state are associated with teen suicide. Given the many other potential variables involved in these studies, we need to hold correlation claims carefullypaying attention to studies that control for more of these variables.

4. Controlled Studies

In the last decade and a half, there have been at least four comprehensive reviews of controlled trials conducted on suicidality and antidepressantsstarting with a 2004 review of suicidal behaviors posted by British regulators (and analyzed here), where they found a 2.62-fold increase in completed suicides and a 2.4-fold increased risk in suicides and suicidal acts for youth taking antidepressants, compared with placebos.

In a 2005 Canadian study, the research team gathered all randomized-controlled trials between 1967 and 2003 in a comprehensive review of 702 studies submitted to government regulators on suicide risk (totaling close to 87,650 patients studied). The key finding from this exhaustive review by Fergusson and colleagues was a significant (more than twofold) increase in the odds of suicide attempts for patients receiving SSRIs compared with placebos or other interventions. 

A similarly comprehensive review happened in a 2006 FDA analysis in the U.S.focused on pediatric data for treatment and suicide. You can find details of that comprehensive write-up (here—all 131 pages), and published formally by Hammad and colleagues in 2006. In lay language, the youth who took the medication in reviewed studies were about twice as likely to have been actively thinking about suicide, or made a suicide attempt, or made preparations to die by suicide, when compared to those receiving a placebo.

As this research team went on to state, “The observed signal of risk for suicidality represents a consistent finding across trials.” They concluded, “When considering 100 treated patients, we might expect 1 to 3 patients to have an increase in suicidality beyond the risk that occurs with depression itself owing to short-term treatment with an antidepressant” (emphasis added).

Finally, in a more recent 2016 review, a research team in Denmark analyzed data from 70 trials (64,381 pages of clinical study reports) involving 18,526 patients, submitted to European and UK regulators. Similar to other studies, they found a doubling of the risk of suicidality for children and adolescents taking antidepressants.

Referring to this doubling of suicidality among those taking antidepressants, Dr. David Healy writes: “This is not an isolated finding, but is the case for almost every single antidepressant studied.” He adds, “No longer can we simply blame the disease: the drugs appear to be playing a role in making some people more likely to take their lives.”

That phrase “some people” is really important here. Dr. Phillip Hickey summarizes:

No one . . . is suggesting that a large proportion of people taking antidepressant drugs kill themselves . . . What is being contended, however, is that these drugs are inducing strong suicidal urges in a relatively small proportion of individuals who had not previously had thoughts of this kind, and that some of these people are succumbing to these urges, and are taking their own lives. This is . . . very important, and it warrants investigation even if it involves only a fraction of one percent of the people taking the drugs. To dismiss these widespread and credible contentions on the basis of the dogmatic insistence that the drugs are wholesome, or that the individuals were probably suicidal to begin with, is simply unconscionable.

I agree with Dr. Hickey. Even if this affects only a percentage of people taking antidepressants, given the large and growing percentage of adults (and youth) now taking them, it seems wrong to do anything other than taking these patterns seriously.

And frankly, that is not what has happened as I’ve shared this data with suicide prevention leaders in recent years.  The concerns have been written off and minimized. It’s especially common for people to dismiss the concern by insisting that suicides worsened following the black box warning placed on antidepressants, but that’s a superficial reading of the data and it’s just not true (see multiple scholars critiquing this conclusion here – and my own analysis here).

It was the Twelve Steps that popularized the idea that the “definition of insanity is doing the same thing over and over again and expecting a different result.”

The existing evidence seems clearly enough to justify serious attention.  Indeed, there is a great deal more evidence than I was even able to include in my longer analysis. As painstaking (and painful) as this tour of the evidence might be, I do so to insist on a more forthright discussion of the question we seem to be avoiding too much: why have suicides been increasing even when we’re doing so much to decrease them? 

Scaling the risk.  Some might reasonably ask, how significant is the risk of antidepressant-induced suicidality across a population of millions of youth?  In the overall “risk-benefit ratio,” could some kind of a risk be worth the benefit of providing help to so many others?

This is precisely what many have concluded.  Lu and colleagues write that, “Undertreating depression is worse than the slight increase in suicidal thoughts antidepressants may cause.” And from this vantage point, one doctor described the “2% absolute increase” in suicide risk as “a minor ambiguous effect.”

This raises the question:  what does it really mean to call the documented increase in risk of youth suicide with antidepressants a “minor effect” or merely a “slight increase”?

A number like “2%” certainly seems small.  And to some, a phrase like “slight increase” will mean something like, “not a big deal, all things considered….or a risk well-worth taking, when you look at the bigger picture.”

To others, however, this risk is not “minor” in the least.  Though this risk may appear small as a percentage point on a page, it becomes more significant when multiplied out to literally millions of kids in treatment across the nation.  As one research team led by Dean Fergusson admits, “It has been difficult to document the relatively rare but very serious risk of suicide,” but adds, “We documented a difference in absolute risk of 5.6 suicide attempts per 1000 patient years of SSRI exposure compared with placebo. Although small, the incremental risk remains a very important population health issue because of the widespread use of SSRIs” (emphasis mine).

In this way, compared to those who say “it’s a very small percentage when you look at the broader population,” there are strong arguments to say that this widespread use makes the risk far more significant than if we were talking about a smaller group of kids taking the drugs. This research team goes on to illustrate that in the United Kingdom alone, “1 million person years of SSRI treatment are provided annually by general practitioners.” If you run the math on that, that seemingly “smaller risk” amounts to 5,600 suicide attempts per year across all of the United Kingdom alone, attributed to the added risk of antidepressant treatment. 

If we were to assume that the general pediatric antidepressant usage rate in America per capita is roughly equivalent to the United Kingdom, then that would translate into many thousands of youth suicide attempts per year in the United States influenced in some way by antidepressants.

Does that sound like a “minor effect” to you? What if one of those “minor effects” is your son or daughter?

It’s been popular to hear comments like “well, all drugs have side effects…and the small risks are worth the benefits other receive” to place in context concerns such as above.

The commitment doctors make to society is to Do No Harm, not Do as Little Harm as Possible.

What I’m not saying. 

No, this does not mean antidepressants aren’t helpful for some people, especially over an initial, short-term period of use. Indeed, as Robert Whitaker has often reiterated, there is an important place for doctors in all this – especially those physicians willing to advocate for thoughtful, selective medical support as part of a larger package of care.  

If nothing else, however, I hope this review makes clear how confusing it continues to be for those of us familiar with this research literature to hear community leaders and prominent psychiatrists insisting that the problem is not enough of our teens and adults accessing (what ends up being mostly antidepressant) treatment.

I hope [this evidence] will help inform a more robust and serious discussion of the question: why have suicides been increasing even when we’re doing so much to decrease them? 

This is not to say that people who have relied on medical support should turn away from that now.  As noted above, any adjustment to a medical regimen should be made cautiously and with appropriate support over time. Rather than encouraging drastic individual changes, let the above be received as a proper, more general caution against our impulse to collectively reach after simplistic answers to a complex problem. 

Rather than simply doubling down on the approach we’ve taken for two decades now, let us pause, reassess, and broaden the conversation to look more carefully at what we’re doing—and what we could do instead. My colleague Ragan Lybbert has called for more attention to the existential angst, despair, meaninglessness and isolation so frequently associated with adolescent suicidality (and yet often overlooked in a crisis intervention model). While rightly prioritizing immediate safety, as our attention expands to include other, deeper concerns happening in people’s lives, the variety and scope of resources to support more sustainable healing is remarkable.

Please don’t ignore this.  The points I’ve raised may be uncomfortable to consider—but not nearly so uncomfortable as the excruciating pain of families who have experienced this unspeakable tragedy (and who will continue doing so). May the infinite worth of these precious lives compel us to not turn away from possibilities we don’t like. And for the sake of those who are hurting the most, may we put every possibility on the table—including those that may demand substantial revision to our accustomed ways of doing things. 

About the author

Jacob Z. Hess

Jacob Hess is a contributing editor at Deseret News and publishes longer-form pieces at PublishPeace.net. He co-authored "You're Not as Crazy as I Thought, But You're Still Wrong" and “The Power of Stillness: Mindful Living for Latter-day Saints.” He has a Ph.D. in clinical-community psychology from the University of Illinois, Urbana-Champaign.
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