- [Dr. Amanda] The Rocky Mountain region of the United States is a beautiful area.

- The American West is known for its beauty and its grandeur, but it's also known as a suicide belt.

- Every demographic group that we look at has higher rates of suicide in the Mountain West compared to the rest of the country.

- Suicide has a huge impact on society in general, on families.

When an individual dies by suicide, the effects are rippling.

- Grief is something that people don't understand.

Until you've experienced it, you have no idea.

- [Dr. Carolyn] Every case of suicide is an individual tragedy with a specific story behind it.

So this is the Mountain West, here at the highest rates for men.

- Suicide, historically despite it being a leading cause of death, has not received very much attention.

- [Dr. Carolyn] It's important that academia get involved in these conversations.

- Suicide is a wicked problem.

There is no one cause even in any single death and there is no one solution either.

- We think that there is a relationship between residing at an increased elevation and an increased risk of suicidal behaviors.

- I'll never in anything else I ever do come across an association that's as strong.

- When you start looking at hundreds of cases of suicide, we can start looking at patterns.

- It's really important for us to continue to do scientific research about this problem into treatments that will work for people.

That's the goal.

- Trying to understand why the suicide rate is so high in the Mountain West is a really complex question.

It's gonna end up being a multifaceted answer.

(rousing music) - [Announcer] Funding for this program is provided by: The Hughes Charitable Foundation, energized by love and faith and inspired by the vibrant community around us.

Hughes Charitable Foundation supports organizations in helping those across Wyoming who need it most.

A private donation from Jack and Carole Nunn, providing statewide support for Wyoming citizens in body, mind, and spirit.

The John P. Ellbogen Foundation, empowering the people of Wyoming to lead healthy lives in thriving communities.

Blue Cross Blue Shield of Wyoming, proudly providing funding for education to raise awareness of the mental health crisis in Wyoming and connect people to available care that promotes positive mental health and hopefully saves lives.

(plaintive music) - I'm a professor here at the University of Wyoming.

My research focuses on self injurious behavior, broadly defined.

So that's anything that somebody does to hurt themselves from things like cutting all the way up through suicide attempts and suicides.

Most people in Wyoming know somebody who's died by suicide.

Today we're gonna be talking about suicide and how we assess it and how we treat it.

If we think about suicide in Wyoming, what jumps out at you when you look at this map?

Katie.

- [Katie] It looks like it has the highest rates.

- Yes.

30 deaths per 100,000 people.

Way above the national average which is 13.

But all through this region, you see the large numbers, Montana, Idaho, New Mexico.

This whole region has the highest rates of suicide in the country.

Every demographic group that we look at has higher rates of suicide in the Mountain West compared to the rest of the country.

The CDC keeps track of every death reported by coroners throughout the country.

We are always this gray bar.

If you can't tell which one it is, it's always the tall one.

So this is the Mountain West, here at the highest rates for men.

And again down here at the highest rates for women compared to every other region in the country.

What about age?

For everybody those go up, but they go astronomically up when you get to older men in the Mountain West.

Trying to understand why the suicide rate is so high in the Mountain West is a really complex question.

I think a lot of people wanna point to one thing as the example or to give us an understanding, but it's gonna end up being a multifaceted answer.

- I think about the fact that people are pretty isolated, given our low population density.

- We're low on resources to even help address this problem.

- Right.

And yet, whatever it is is happening in Denver.

It's not just that maybe there aren't enough healthcare providers in a rural area.

It's not just loneliness in rural areas.

I'm not saying that those aren't factors, but that's not gonna be the whole story.

So the big question, why?

It's important that academia get involved in these conversations.

So we can look at patterns that emerge in the Mountain West and academics are well suited for those kinds of studies and try to help understand what's going on.

- There's something we call sort of the paradox of happiness in the Intermountain West, which is that although rates of suicide seem to be higher here, people often report a much higher quality of life.

- And everyone's skiing and mountain biking and climbing.

People will tell you, "I'm really happy, but I wanna commit suicide."

You know, which is mind boggling 'cause that doesn't make sense at all.

- My area of of primary research interest is how the brain chemistry is altered in people with mood and anxiety disorders.

And in 2008, began studying these changes in brain chemistry that might underlie the emergence of suicidal symptoms.

Are we missing the boat in terms of some things we could be doing to improve outcomes?

We have benefited enormously from collaborations that we have from colleagues in different departments.

- I spend a lot of time thinking about the epidemiology of suicide.

Overall, it's the 10th leading cause of death.

We often refer to this area, so the Rocky Mountain states with the highest suicide rates being the suicide belt.

So as a biostatistician and epidemiologist, I look at data, I do a lot of statistical analysis coding.

We have a longstanding collaboration with our Office of the Medical Examiner where they make a determination of cause of death.

- I work for the Utah Office of the Medical Examiner.

My job there is to provide near real-time surveillance of suicide death in our state.

So our data simply is counting the number of people who are dying by suicide and trying to keep a closer track on perhaps the reasons they're dying.

We also speak to families in the wake of their loss.

These are sometimes referred to as a psychological autopsy because we are missing all kinds of really important information about that person.

- For suicide risk, historically, there has been a heavier focus on major life events, the role of mental health.

And so our central question is trying to understand what drives suicide risk, what makes some people more susceptible, vulnerable than other people?

More recently, we have had a shift in our paradigm of thinking there may be other risk factors like environmental factors such as air pollutants.

So this is what you know we found overall here in Salt Lake County in terms of the relationship between short-term ambient air pollution and risk of suicide death.

We've seen increasing evidence that air quality, air pollution impacts suicide risk.

- We have a lot of pollution here in Salt Lake City because we live in a natural bowl that catches all the pollution that we produce.

Some days in the winter you look out from a window like this and you can't see the hills across the way because of the smog.

The pollution that we're making doesn't go anywhere, it just gets trapped here.

- Our meteorological or weather variables, they can actually play a role in suicide risk.

We see a relationship between increasing solar radiation and increasing temperature and risk of suicide death.

We also have some additional hypotheses about maybe residing at an increased elevation such as above 2,500 feet elevation and an increased risk of suicidal behavior such as suicidal ideation.

- I'm part of a big research group led by Perry Renshaw primarily, and I guess I would say he's sort of the godfather of altitude research.

- There's an amazingly tight association between rates of suicide and altitude.

I'll never, yeah, in anything else I ever do, come across an association that's as strong.

- Before us, some folks in Ohio found the altitude of capital cities in the Intermountain West associated with increased suicide rates.

And added to that, that's all the epidemiological data, which is pretty compelling, there's a lot of the basic science which shows that altitude and hypoxia can affect the brain in lots of different ways.

Everybody experiences this when they go to altitude.

A little bit less oxygen means that you're a lot more tired, you're not able to work out very much.

If you go to really high altitude, your brain stops working and you get confused.

I've had one panic attack in my life, fortunately.

That happened when I went from sea level and up to about 10,000 feet so that happened over the course of the day.

So you can certainly see neuropsychiatric effects almost immediately.

But the effects that we're interested in with respect to producing suicide death are probably happening over the course of years.

- [Dr. Shami] We decided we would look to see if there was a biological impact of hypoxia.

We're looking at chronic exposures.

I'm a neurobiologist by training so when I first heard Perry talk about hypoxia affecting behavior, I was all for doing the experiments to determine whether or not that was true.

But it was kind of iffy, you know?

Now, in an animal model you can't really study suicide, animals don't suicide.

But you can study depression and biological risk factors for both depression and suicide.

So we put the animals in their cages into the chambers at sea level versus 4,500 feet and they just stay in their cages.

They just go about their business in their cages like they would do outside.

And then we have the forced swim test, and what you do then in that five minute period, you determine the percent of time that's spent actively trying to get out.

So it either swims, it dives, it climbs up the walls, and the walls are high enough that it can't jump out.

Or at a certain point, it gives up.

It's called passive stress coping.

They could float on there indefinitely.

- Generally speaking, it makes them act very depressed and less willing to overcome stressors.

So we often talk about depression as a sort of learned helplessness, right?

So it's sort of hitting stressors and not being able to overcome them and then effectively giving up.

And I think a lot of people who struggle with depression experience it that way so learned helplessness is the animal model of depression.

- At the end of each experiment, blood is collected and we process these for different markers such as brain serotonin.

Animals housed at moderate altitude exhibit biomarkers for clinical depression, reduced brain serotonin, reduced brain dopamine.

We were pretty clear that this is a biological impact.

- There's a great study coming out of the University of Utah where they look at the neurobiology of people at mountain towns.

And what they found is that certain neurochemical indicators differ between people at high elevations and low elevations.

And what the science is showing is that people at higher elevations have a different neurochemistry than people at lower elevations.

- Serotonin is critical for reducing both anxiety and depression.

If you stop making serotonin, you're going to have more depression, it's going to be harder to treat.

Higher altitudes also decrease dopamine synthesis, which is the other transmitter system that we think is highly related to changes in the brain chemistry.

- The brain's production of serotonin depends on how much oxygen is available because one of the enzymes that produces it needs a lot of oxygen in order to function.

And we know that if somebody is relatively hypoxic, it reduces serotonin production in their brain.

There have been older studies that have found that lower serotonin levels are associated with suicide death.

What kind of general health conditions do you have?

One thing that that could imply is that traditional antidepressants like Prozac don't actually have as much effect at high altitude because there's not enough serotonin initially to increase at the synapse.

My part in the research is working with patients in clinical trials.

We've looked at brain energy storage using a lot of the neuroimaging techniques we have available here.

Your brain is about 2% of your overall body mass and it uses about 20% of your overall energy.

Oxygen availability is one of the things that most powerfully affects how much energy is available.

People with depression have relatively low brain energy so we want to show that depression, suicidal ideation, other mental disorders are ultimately physical illnesses, they are due to brain abnormalities because one thing that we really want to do is translate our theories about how altitude contributes to depression and suicide into treatments that will work for people.

That's the goal.

Do you think that we've got enough detail here in the frontal cortex?

- [Technician] The data quality is pretty good.

- But the reality is that none of us think that altitude is the only thing that causes high rates of suicide in the West.

There are lots of other things that are probably happening.

- There might be some biological factors involved, but those models don't explain individual differences within people or across different groups of people.

We need to think about the biological, the social, but also as a psychologist, I'm interested in the psychological processes.

I'm here at the University of Wyoming.

Our mascot is the cowboy image.

We value that cowboy mentality.

We value problem solving.

- For a person in a frontier state, the worst kind of outcome they can predict is hitting up against a problem that they can't solve.

- [Dr. Carolyn] So part of what goes along with this culture of sometimes we think of it as masculinity or a culture of honor is a stoicism, especially if you're an older white man who grew up with that as your culture.

Another group that has really high rates of suicide in the Mountain West is Native Americans.

Their suicide rates can't be accounted for entirely by the altitude.

There's some other things going on with the way that they have been sent to reservations and live their life in a very different way under a lot of burdens from the rest of the country.

- I personally know that growing up, we didn't talk about our problems because of the trauma and the historical trauma that we've all been through.

We were taught to stay silent.

We were taught to keep everything secret.

And now I am on the other side of it, I was able to recognize that I needed the help.

- [Dr. Carolyn] So for our lab meeting today, we're gonna be talking about the interpersonal theory of suicide.

What comes to mind as things that might be cultural factors for older white men that might contribute to their rates of suicide?

- I feel like a lot of older men, they grew up in a generation where they felt like they were very important to society.

As they get older, they lose that purpose.

- Bereavement, loss of social support.

- Feeling like you are isolated.

When you start looking at hundreds of cases of suicide and thousands of cases through the region, we can start looking at patterns and we can start hopefully identifying some factors that can help us identify the people who are particularly at risk.

The next part of the interpersonal theory of suicide is this acquired capability for suicide.

The things that make people more likely to die by suicide is if they have built up a pain intolerance and then they have gotten over their fear of death.

- People who live on ranches, a lot of people in Wyoming do, - Exactly.

- They're very used to death.

- [Dr. Carolyn] If you grew up using guns for hunting, it becomes something that's normal and something that you are skilled at.

- There's a lot of availability of firearms in the West.

In Utah, over half of the people who die by suicide every year use a firearm and in other states it can reach nearly 70% year over year.

I'm a gun owner.

This is not a commentary on the Second Amendment rights, but we know that when alcohol is involved and easy access to a firearm and a crisis like an argument, that triad is a really dangerous combination.

- I tried ultimately taking my life in 2019 with a self-inflicted gunshot wound to the head.

Just pulled the trigger out of impulse.

- What I learned from what happened to Cole is, geez, it seems like every month you read about a teenager, a 20-year-old or something that took their life in Wyoming and this is real.

- Once you have experienced suicide, you are more aware of suicide as a possibility.

So if you're in a community where there's a lot of people dying by suicide, that can be enough to tip somebody towards suicidality.

- There was one suicide attempt a week later by a different friend of mine, and then two other attempts within the last three months of friends of mine.

- The CDC defines a suicide cluster as three suicide deaths that occur within a certain period of time.

One of the ways that my job in that near real-time surveillance is the most valuable is to prevent suicide clusters.

There is no silver lining here, but what can we learn to prevent somebody else from making this horrible decision?

- The point is to reduce our rates of suicide death and to come up with more personalized individual approaches.

The more we understand the risks for different people, the more we can intervene on those specific risks.

- So I think the scientific research offer some hope that things could get better over time.

We're looking at nutritional supplements that we think might correct some of the deficits caused by low oxygen and preliminarily, a lot of that research is really promising.

One marker of brain energy is something called phosphocreatine.

So that's the creatine that you get from a nutritional supplement.

- Creatine is used by 62% of all high school football players in the United States and so it's had its trial by fire.

Creatine monohydrate increases brain energy stores and it's the most extensively studied nutritional supplement in terms of effects on the brain.

- Because with low oxygen produces low brain energy, the creatine that we're using basically gives you a bigger battery so that you could store more energy when you manage to produce it and then that can drive brain processes when you need it.

- One of the things I'm excited about is we're looking at the impact of novel therapeutics for depression at altitude.

So what we've been doing is feeding these animals bioenergetic compounds like creatine, and can actually improve energetic function.

My next goal is to actually look at several different bioenergetic compounds in this animal model to see if we could actually come up with compounds to target for depression in people at altitude.

- And then the other thing is 5-hydroxytryptophan or 5-HTP.

The way the whole tryptophan hypothesis works is you eat trytophan from turkey or something else, and then it gets converted to 5-HTP and then 5-HTP gets converted to serotonin in your brain in an oxygen independent step.

So if we give people more 5-HTP, then potentially they can produce more serotonin even though they don't have any oxygen.

- 30 years ago we thought that the way that you treated suicide was to treat depression.

Not everybody who comes in with suicidal thoughts and plans is depressed.

One of the things we need to do is make sure that if you go to get help for your suicidality, the person who you're seeking help from is equipped to help you.

- We're all living a more similar life than we realize.

A lot of people feel lonely and a lot of people feel depressed.

A lot of people feel anxious.

- Yeah and if nobody puts out there when they're feeling sad or lonely, then those normal feelings that we all have then become something to be shameful or feel shameful of and then you don't have anybody to talk to.

We're trying to find ways to increase the number of mental health providers here in Wyoming.

We need to make sure that that provider understands suicide.

So we need to learn how to assess and then how to treat suicidality for everybody who we're meeting with.

- Part of what I do is getting people to be vulnerable and risky in a different way from an emotional standpoint.

A lot of people are very familiar with and comfortable with the physical risk that comes with being in a frontier state, my job is to help people get a little more comfortable with the emotional risk of opening up.

- Alright, we'll see you soon.

- [Ryan] We're taught to be independent but sometimes with mental health, the answer isn't to fight through it on your own, but to find resources and find tribe.

Anything that gets people together to realize that they're not alone is gonna help this sense of loneliness and isolation that comes from living in a frontier state.

- One of the things that people can do to reduce risk of suicide, this is absolutely shown in the research, is developing a sense of community.

- Anything that helps people feel involved or connected to anybody can be useful.

So even having a short phone call with a friend is a step in the right direction.

But really, it can be as simple as meeting a friend for coffee.

You don't even have to talk about your problems.

Just having that interpersonal connection.

- Generally speaking, being a member of a church, being part of a religious community is really protective against suicide and other mental disorders because you have a sense of community, you have a sense of belonging, a sense of purpose.

Having good intimate relationships with supportive caring people, having activities that put you in touch with other people face to face.

- I believe that folks need an avenue or a venue or an opportunity or way to talk about what they're struggling with.

- And that's the problem with modern society is that we can hide so easily.

So someone with depression, it is really just saying, "I can't do this on my own."

That's a societal wound and it needs a societal remedy.

We can't put more pressure on the individual to fix themselves, right?

That's part of the problem, is we're saying, "This is all on you."

- The stigma associated with mental disorders, including depression and suicide is due to the idea that they are a personal failing or the result of some personal failing.

You're not trying hard enough, you're not a good person.

But if we can show that there's a biological basis for it, then it gives people a sense that they're not really at fault, right?

It's things outside of them.

- So we do this work not to say everyone should immediately move to the beach, but precisely because if we understood the phenomenon better, we think we would come up with better treatments.

And our treatments are imperfect.

You know, we've known all of these things for a long period of time, but what we haven't had is a convenient way to use evidence-based treatments to improve outcomes and that's what this is about.

It's an opportunity for researchers to make a difference.

- We count on science to answer our complex problems in the world and I don't know that we have very many more complex problems than why an individual dies by suicide.

And then we can use science to study our treatments so we can be better equipped to design interventions to help the folks who really need it, and then test those interventions to make sure that they're working.

- When you learn about the neurobiology of what's happening in your brain, you just have space to open your peripheral vision to see options and opportunities that you may have missed before.

- Suicide is a community level event, it is a state level event, but also that there are things beyond our individual control that we don't really fully understand.

Those are things that we can explore scientifically and to do better suicide prevention because that's where I find hope in all of this and make sure that the people who are experiencing a crisis can find it also.

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