Special Reports

BREAKING THE SILENCE: Rural areas have higher suicide rates

Oregon’s suicide rate has been higher than the national average for the past three decades. More than 800 people killed themselves last year in Oregon.

The problem affects everyone. Suicide is the second leading cause of death for young people, but 90 percent of Oregon’s suicides are by people older than 25 years old. Most suicides are men, but it crosses social, economic, and geographic boundaries.

The highest rates are shared by groups with deep historical and cultural differences—white men and Native Americans. One in every five suicides is a veteran.

These heartbreaking statistics are part of a longstanding and perplexing pattern of higher suicide rates in the West. For decades, the western half of the country, stretching from Montana to Texas and west to California and Alaska, reported persistently higher suicide rates.

Now they are highest in the Rocky Mountain states and Alaska, with Oregon not far behind.

No one really knows why.

“Not only are they persistently high, but they are rising everywhere,” says Carolyn Pepper, a Wyoming researcher studying suicide in the mountain West. “That’s the big question I don’t think anyone has a good answer for.”

Researchers have been looking for answers. Understanding the high rates in the West and in Oregon may point to more ways to help people find hope and support to make it through their darkest hour.

In parallel, health officials are looking at local data in new ways to find effective places to intervene.

“We’ve gotten to the place where we know there are solutions,” says Trena Anastasia, a suicidologist in Colorado. “For many, many years, we thought if people want to die by suicide, they will find a way. No one really wants to die. They really want to escape the pain they’re in. One of the first things we want to do is make it OK to seek help.”

When she moved to Bend last August, Abby Woods, 15, tried to seek help after being bullied at her new school. She tried one psychologist who wasn’t a good match, and then got on a three-month waiting list for someone who specialized in adolescent psychology. She switched schools and talked to her parents, but it wasn’t enough to cope. She made a suicide attempt in late October, before her first appointment.

Now, she will be putting her lived experience to use helping others. She has volunteered for YouthLine, a service of Lines for Life, which is adding another teen help line call center in Bend this summer.

“The other volunteers doing the training are awesome,” Woods says. “They are kind, compassionate, empathetic. There’re good people out there. I finally found them.”

For teens who want to talk to teens, YouthLine is available daily 4 to 10 pm with free, safe, anonymous teen peer support by text (“teen2teen” to 839863), chat (OregonYouthLine.org) and talk (877-968-8491). Phone calls are answered 24/7/365.

In trying to understand the overall higher rates of suicide in the West, some researchers have looked at the physical surroundings. For example, many Oregonians typically welcome spring and summer with a lifting of spirits after a long dark gloomy winter, for example, yet recent Washington County data shows suicide rates climb in spring and peak in August.

This turns out to be a longstanding seasonal pattern in many countries. It’s another suicide myth that winter holidays prompt more suicides. In fact, the shortest, darkest days are one of the statistically safest times.

Other researchers have wondered if altitude raises the risk of suicide. When Perry Renshaw moved to Salt Lake City from the Boston area, he was astonished by the map of U.S. suicide rates with its dark swath of high rates from Alaska down through the mountain states. At the University of Utah, he was continuing his brain imaging studies about how the brain uses energy to navigate the challenges of mental disorders.

His team analyzed state and county data and found strong correlations between altitude and depressive episodes. Similar reports have since come in from researchers in other countries. In animal studies, mice also feel worse at higher altitude. It turns out that thinner air causes oxygen deprivation, and oxygen is required for the first step in making serotonin, a neurotransmitter in the brain whose low levels are linked to depression.

The effect begins at elevations as low as 2000 feet above sea level. It’s not just living at high altitude. In the literature, this hypoxic state also happened in asthma, chronic lung disease, congestive heart failure, sleep apnea, and anemia.

The findings may have therapeutic implications. For example, some antidepressant drugs work by preventing serotonin from exiting the brain, but if low oxygen is keeping enough serotonin from being made in the first place, those drugs may not help.

Renshaw’s team is now testing another option in people. They want to learn if supplying the last step in making serotonin, which doesn’t require oxygen, will lift depressive moods, which may contribute to some suicides. The potentially helpful molecule is sold as a nutritional supplement in health food stores.

“We don’t think it’s so simple to be just about altitude,” Renshaw says. “It’s not the only thing by any means. But it seems remarkable how much could be related to altitude. If that were the case, we could do a much better job of providing treatment than we are doing now.”

A more established link comes from the fact that suicides are higher in rural areas, and many people in the West are scattered in those vast expanses, isolated from each other and from mental health services in small towns, farms, ranches, deserts, and forests.

That’s true in Oregon as well, with rural and frontier counties having the highest rates, about 23 per 100,000 for the last six years analyzed, compared to 16 for urban counties.

The rural-urban divide doesn’t explain everything. Cities in mountain West states also have higher rates of suicide compared to other U.S. cities, Pepper found in a recent study. There is a western effect raising rates in both rural and urban areas, men and women, all ethnic groups, and all ages, she said. For this article, Pepper ran her analysis on Oregon data and found a similar pattern.

“There is a clear correlation between the urbanization level of the county and the age-adjusted suicide rates, with higher rates generally in more rural areas,” Pepper reported in an email. “The rates in the cities in Oregon are not quite as high as the cities in the Mountain West, but [are] higher than other parts of the country.”

Pepper suspects a prevailing Western cowboy culture of pathological self-reliance and stoicism may be partly responsible. These are early days in her research. She’s in the middle of a study of attitudes in the West and other information using Amazon’s Mechanical Turk, a web site designed to enable companies to crowd source tasks to a distributed workforce. It enables her to tap into broader cross section of people than the usual university undergraduates enticed into psychology experiments.

“Maybe Wyoming isn’t full of people who value rugged individualism, but they think everyone else does, so that might affect how they behave,” she says. “Rugged individualism is a belief that you should be able to solve your own problems, but if you can’t, then you’re left without a second option.”

Colorado researcher Silvia Canetto also sees a strong cultural signature influencing U.S. and Western suicide rates that may be largely invisible to most people. To her, it makes no sense to think about suicide as a death of despair in people—white men—who have historically dominated the culture as a group, if not always as individuals. Instead, she sees permissive attitudes and beliefs about suicide as a lingering European heritage, especially when facing physical illnesses.

“Suicide is complex,” says Ellyson Stout, director of the Suicide prevention Resource Center in Massachusetts. “There’s no one cause or factor that can explain the higher rates in Western states.”

That applies to prevention as well, she said. “What we do know, it takes multiple strategies working together.”

Nothing predicts suicide better than gun ownership, which is higher in the West, says Dr. Matthew Miller at Northeastern University in Boston. “If you have guns available when you’re attempting suicide, you’re more likely to die.” That’s important, he says, because more than 90 percent of people who survive a serious suicide attempt don’t go on to die of suicide.

“Rather than be agitated by it, let’s do some good with it,” says Michael Anestis at University of Southern Mississippi. Around the globe, researchers have found that suicide rates plummet when the most common methods are eliminated, he says.

Discussion with gun owners about limiting their access to guns can be contentious. To help prevent impulsive suicides, Susan Keys and her colleagues in at Oregon State University Cascades in Bend have developed a strategy that centers on respect for gun rights.

Dr. Laura Pennavaria, chief medical officer at St. Charles Bend hospital, became interested in suicide prevention after a local teen died by suicide.

She took the gun conversation training and participated in a pilot study of the approach at the La Pine Community Health Center. “I have had patients tell me those conversations have prevented them from killing themselves,” she says. “That’s not data, but I suspect it is very effective.”

The focus on suicide prevention is starting to work.

In 2012, Washington County’s suicide rate was hovering close to its all-time high. A multidisciplinary team formed to ask the same question as anguished families and friends: Why? In response, they developed an in-depth analysis of each suicide and asked families for permission to investigate medical, financial and other factors of people who died.

With more complete data, they were able to investigate and discover unique touch points where people go when they are imminently suicidal, such going to a budget hotel or to a health care provider, or taking a loved pet to an animal shelter. When they identified evictions as a trigger for some, the sheriff suggested including crisis line information and a member of the mental health crisis team when serving evictions.

The suicide rate has dropped 40 percent since 2012, says Washington County epidemiologist Kimberly Repp. That’s the county’s lowest suicide rate in 10 years.

Roger Brubaker, suicide prevention coordinator in Lane County, hopes to develop a similar system of real-time public health surveillance. He receives immediate alerts about teen suicides, but there is a one-to-three year lag time in learning about other suicides, the risk factors, and potential ways to intervene.

In the meantime, he conducted a thorough analysis of Lane County suicides from 2000-2016 and presented it in a public forum last October in Eugene. The report found older men were overwhelmingly at risk and, importantly, not being reached with suicide prevention messages. And the rates were highest in the coastal city of Florence.

“There is a lot of work around youth, because there are a lot more youth attempting suicide, and that impact is felt differently, but the people dying are mostly middle aged adults and mostly men,” Brubaker says. “The weirdest thing in suicide prevention is that the people most likely to die get the least attention.”

A pilot program to identify and reach out to veterans at highest risk of suicide uses a computer analysis of their electronic medical records. Living in the West is enough of a suicide risk factor that it is one of dozens of data points considered.

Called REACH VET, the program was launched in February 2017 and applies to veterans enrolled in the Veterans Health Administration. In a preliminary six-month evaluation, it increased health care appointments and reduced deaths by all causes. It’s too early to know what impact it will have on suicides.

Disabled veteran Broderick Pruitt found his own way to the Portland VA, overcoming a stigma of seeking counseling he found prevalent in black communities. It was the second time he turned to the military to save himself.

The depression and PTSD that led to a suicide attempt arose not in military service, but from his rocky childhood in a picture perfect New England town.

Pruitt uses a wheelchair after developing a painful back condition working as an aid in an elderly living facility. He has benefitted from learning a new skill set to confront negative inner voices in the Portland VA. The weekly drop-in Wise Warrior support group is especially valuable, says Pruitt, who also credits a newfound Christian faith that sustains him.

Veterans, their friends and family can reach out for free confidential help by phone (800-273-8255, press 1), Text (838255), or chat (https://www.veteranscrisisline.net/).

The science of suicide prevention is relatively young and underfunded, experts said. Suicide may be one of the leading causes of death in the United States, but it receives a fraction of research money devoted to thwarting other killers, such as heart disease, cancer, and infectious diseases.

Much of the research has been driven by youth suicide prevention and by a program born of an Oregon family’s tragedy. In 2004, federal funding became widely available for the first time to states, tribes, and colleges across the nation to implement community-based youth and young adult suicide prevention programs.

The funding is named after Garrett Lee Smith, a graduate of Pendleton High School and the son of Gordon Smith, the former U.S. senator from Oregon. One day shy of turning 22, Garrett killed himself in his apartment in Utah, where he attended college.

Smith funding, combined with a comprehensive approach, appears to have slowed the increase in suicide rates for youth under age 24 in counties across the country, says Meghan Crane, Oregon’s Zero Suicide Program Coordinator.

The federal money to launch suicide prevention programs for youth came before any evidence existed about what worked, so people have been learning on the fly.

“It’s a scary field,” Anastasia says. “You can’t just go out and talk about suicide without safety precautions in place to make sure the people you are talking to are safe.”

In 2005, researchers demonstrated for the first time that asking high school students at high risk of suicide about their suicidal thoughts did not increase distress or suicide attempts, said lead author Madelyn Gould of Columbia University in New York.

“It was prompted by the prevalent resistance to ask about suicide, particularly in school settings, because of the prevailing belief (actually a myth) that asking people about suicide would put ideas in their heads,” she wrote in an email. “This resistance was widespread, and even clinicians would sometimes voice a concern about asking a patient about suicide.”

The findings have been replicated in other populations. The results were meant to build a case for school-based suicide screenings, but Gould has heard that others have used the findings to convince reluctant human-research review committees that suicide prevention research could be done safely.

In fact, suicidal thoughts are surprisingly common. Several researchers and survivors interviewed for this article consider suicidal thoughts part of the human experience.

Every year, at least 10 million U.S. adults experience suicidal thoughts and feelings, said Eduardo Vega, a Los Angeles suicide prevention expert last month at the Oregon suicide prevention conference in Sunriver. It least 1 million Americans try to kill themselves annually, and about 45,000 people die as a result.

In Oregon, for every suicide, 280 people consider it and do not go through with it.

It’s important that more people than ever are reaching out for help, especially to help prevent lethal behavior. But the rising death rates means something is still missing, says Vega, who survived two near-fatal attempts about 30 years ago and lost his cousin to suicide last year.

Vega finds hope and value in the human struggle. “It’s not pretty,” he says. “I don’t wish these experiences on anyone.”

But “what you are experiencing is not fundamentally bad,” he says. “It doesn’t make you abnormal. It’s an interesting, powerful human experience.”

Woods, the Bend teenager, wants to share this message.

“It is so important to reach out and advocate for yourself when you are in such a dark place,” she says. “There are alternatives to suicide and there is hope. I have been in that dark place where it feels like it will never get better, and I know how that feels. And I know that everyone probably tells you it will get better, and I know that you probably don’t believe them.

“But from being in your same situation, I can guarantee that if you just hold on a little longer, life does get better. And you will get through this and there are people who need you. So please, if you need help, reach out. Take initiative and get the help that you deserve.” 

This story was funded by a journalism grant from the nonprofit National Institute for Health Care Management Research and Educational Foundation (NIHCM).

ABOUT THIS PROJECT: Newsrooms across Oregon this week are sharing the results of a unique collaboration to delve into suicide and suicide prevention. Each newsroom acted independently but shared research on aspects of suicide. All of the coverage through the week of April 7 can be found at breakingthesilenceor.com.

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