Building community: Identifying solutions to the mental health problem
Summit Daily News
The suicide rate in Summit and other mountain communities is consistently higher the national average. Of the 10 states with the highest suicide rates, eight were in the Rocky Mountains region: Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah and Wyoming.
A variety of sociological factors — such as the rural and isolated nature of mountain communities, financial stress, a shortage of mental health providers and higher rates of substance and alcohol use — have been blamed as possible reasons for high suicide rates in the mountains.
Given the kaleidoscope of individual experiences and the complex nature of mental health, no single factor, or even group of factors, has been definitively proven to create the nexus for suicide, though many factors can have a part to play. We know there is a higher rate of suicide at higher altitude, but the mystery persists as to why. Is it sociological, economic and cultural factors, or is there a biological link between high altitude environments and suicide or suicidal ideation?
Mind over mountain
Mountaineer and explorer Mike Libecki has been through all of it and more.
Libecki has made more than 90 expeditions across the planet, with most taking him to places few — if any — humans have visited. He completed the first solo ascents of jagged, vertical cliffs in the mountains of Afghanistan with sand in his eyes while watching for the Taliban, which laid claim to the land.
He’s been to Antarctica, accomplishing technical climbs on the world’s coldest mountains, where temperatures can dip to minus 100 degree territory and where rescue is impossible.
Libecki also has bushwhacked his way through the most remote and wild jungles of Papua New Guinea, where he sweltered through 98% humidity and avoided the “madness” of never-ending rain and bugs, just to climb rock faces that nobody had ever thought to climb before.
Libecki’s extraordinary journeys earned him the title of National Geographic Adventurer of the Year in 2013. He doesn’t do these adventures and climbs for accolades but rather the sheer organic enthusiasm that comes with connecting with nature in the most remote parts of the planet, a mad obsession that brings him inner peace.
But through all his hair-raising trials and tribulations, like being 20 seconds away from being crushed by rockfall, Libecki has learned to respect and nurture the one constant companion that is with him when he scales the world’s most remote mountainsides and returns home with him when he reunites with his daughter: his mental and emotional health.
“In my opinion, there is nothing more powerful in our human experience than human emotion,” Libecki said. “As far as altitude and these big walls, the challenges are simple to figure out: You have to plan, prepare and physically train. There is no mystery there. You’re acclimated. You’re hydrated. You’re strong. The mental part of it, you can’t train.”
Libecki explained that with what he does, he has to rely on a hyperfocus that can be attained only with a clear mind.
“You need to be making good choices, have a clear focus, be clear minded and emotionally stable. You can’t be out there and be occupied with issues with family, home, life,” Libecki said. “If you don’t have the clarity and the focus to be hyperaware and hyperfocused and hyper in the now, nature will turn you into fertilizer.”
His adventures have brought near-death experiences that still flash before his eyes and cause distress when he recalls them. The power of those emotional experiences is a reason why he sees mental health care as a priority.
A silent epidemic
Mental health has become a priority agenda item in communities across the United States. In 2017, suicide rates reached an all-time high in Colorado (1,175) and across the U.S. (47,173). Summit County had an all-time high of 13 suicides in 2016, going down to five in 2017 before jumping to 11 in 2018.
Summit is an adventurer’s playground, but good physical health does not necessarily translate to good mental health, as shown by Summit County’s high suicide rate.
Relatively few research studies have been conducted to find the impact high altitude environments have on mental and behavioral health. Theories have been posited about what hypoxia, or low oxygen concentration in the blood, does to the brain and the way we think and feel, but there is not enough data to support these hypotheses or find the exact mechanism by which those changes occur.
In 2017, researchers from the Department of Psychiatry and Brain Institute at the University of Utah in Salt Lake City published a review article in the “Harvard Review of Psychiatry,” titled “Living High and Feeling Low: Altitude, Suicide and Depression.”
The article, published by Dr. Brent M. Kious and colleagues at the University of Utah, reviewed 12 studies performed on high altitude populations, mostly in the United States, to find whether there was a significant link between high altitude living, depression and suicide.
The research compiled in the article consistently showed a positive correlation between suicide and higher altitude living. One of the studies found that suicide rates increased as altitude increased — even as death from all other causes dropped.
Another study found a stronger correlation between suicide and higher altitude than between suicide and gun ownership. A 2006 study of 8,871 suicide deaths in 15 states found that the suicide rates, when adjusted for population distribution, were 5.7 for every 100,000 residents at low altitude, 11.9 at middle altitude and 17.7 at high altitude.
Yet another analysis of 35,725 suicide victims from 2005 to 2008 representing 922 U.S. counties found that altitude was a “significant, independent predictor” of suicide for those affected by bipolar disorder.
While most of the research was focused in the U.S., research done in other nations has shown a similar correlation between high altitude and suicide rates.
Andalusia, an autonomous mountain community in southern Spain, had a higher suicide rate than the rest of the nation. The positive correlation went as far as the individual towns in Andalusia, with higher average altitude correlating with higher suicide rates.
Another study in South Korea from 1997 to 2007 found that suicide was “strongly correlated” with altitude, with a 1.5% increase in suicide rate per meter increase in mean altitude. A study conducted among electrical workers in Peru, where much of the country’s territory is dominated by the Andes, found that workers stationed at nearly 10,000 feet above sea level showed significantly more symptoms of depression and anxiety than workers stationed at sea level.
Based on rat studies and short-term studies on humans at altitude, the authors of the article theorized that “chronic hypobaric hypoxia,” permanent hypoxia caused by changes in barometric pressure, might have something to do with the high suicide rates at higher altitudes.
The authors posited that “hypoxia could promote suicide and depression by altering serotonin metabolism and brain bioenergetics.” Both biological processes have something to do with depression and both are affected by lower blood oxygen saturation.
However, throughout the article, the authors caution repeatedly that socioeconomic and demographic factors, such as poverty and individual community pressures and influences, might have an impact on the statistics that cannot necessarily be measured, even after trying to control for those variables.
With a grain of salt
Dr. Benjamin Honigman is the director emeritus of the Altitude Research Center based out of the University of Colorado Anschutz Medical Campus, which is partnering with St. Anthony Summit Medical Center to create the High Altitude Research Center in Summit County.
Honigman said he is interested by the findings in the University of Utah study but strongly cautions against using them and some others as the final, definitive say in whether high altitude leads to higher suicide rates.
“My worry is that we’re trying to simplify a very complex problem,” Honigman said, noting how the article mainly reviewed epidemiological studies across large populations, which would be unable to properly factor in or control concerns specific to every individual, such as financial distress, access to firearms and access to mental health care.
Honigman, in association with Dr. Elaine Reno at the University of Colorado and other colleagues, published their own review article last year in the medical journal “High Altitude Medicine & Biology” titled “Suicide and High Altitude: An Integrative Review.” Their review also supported a possible association between high altitude, depression and suicide.
However, Honigman and his fellow authors were not convinced the existing data was sufficient to make any definitive correlation between high altitude and suicide. The authors note that two of the states with the highest suicide rates — Alaska and South Dakota — are at or near sea level with similar socioeconomic and demographic concerns, such as poverty and substance abuse.
Furthermore, the data showed that Native American Indian reservations in the U.S. had the highest rate of suicide, but the vast majority of those reservations are at sea level, weakening the idea of a correlation between altitude and suicide.
The authors also were skeptical of the existing population-based studies because they cannot properly account for individual factors. Honigman called it an “ecological fallacy,” where the characteristics of a large group are used to describe the characteristics of an individual.
“There are very few studies that have the capacity to look at individuals and what their individual characteristics are as it relates to employment, depression, firearm ownership and access to mental health care,” Honigman said.
The authors called for more clinical research on the biological factors at play. Honigman said that rat studies are not a sound basis for determining the factors such as serotonin levels affecting human behavior, as it is hard to translate possible depression or suicidal ideation in rats to humans.
The authors also said that the short-term clinical research used in the Utah study does not cover aspects of long-term health at altitude that would be more dispositive of a definite link between high altitude and brain chemistry. Given the many changes happening to the body at higher altitude, the authors were not convinced that just a couple of factors such as serotonin metabolism were the only mechanisms that might affect mental health at high altitude.
The bottom line for Honigman and his co-authors was that much more research needs to be done to find any causal link between high altitude and suicide with more scrutiny given to factors that affect individuals rather than to broad swathes of population. The authors maintain that external sociological factors — not biological — have more to do with higher suicide rates in mountain communities.
“This integrative review of the current literature confirms that there are higher suicide rates at high altitudes, but the cause of this correlation remains incompletely explained,” the authors wrote. “Suicide victims at high altitudes differ significantly from those at low altitudes in multiple demographic, mental health and suicide-related characteristics. These other factors, rather than hypoxia, are more likely and more plausible explanations for high suicide rates at high altitudes. Regardless of the cause, clinical professionals at high altitudes should be especially vigilant concerning this public health issue.”
Honigman said he has a “major concern” with the possible takeaways people may get from the University of Utah article, including not looking at mental health treatment as a primary means of treating depression and suicidal ideation.
“People are always looking for silver bullet or an easy magic solution,” Honigman said. “If the lay public begin to believe that all they need to do to avoid depression or suicidal ideation is to have more oxygen or to take a pill, as opposed to getting treatment for mental health and exploring what emotional issues they are dealing with in their lives, I think it would do more harm than good.”
Regardless of why suicide rates are higher in the mountains, communities like Summit County have been struggling with the real-world fallout of lives cut short, often for reasons unknown to people around them.
When suicides hit a record high in 2016, the community realized a concentrated effort was needed from all corners of the community: health care providers, government, schools, local businesses and ski resorts, nonprofits and law enforcement.
The Summit County government joined with nonprofit groups like The Summit Foundation and the Family & Intercultural Resource Center to grapple with the crisis. One solution came in the form of a homegrown nonprofit called Building Hope.
Building Hope’s mission for the past three years has been to help Summit County residents connect to the resources they need for better mental health. The organization has been working to identify the sociological reasons for depression and suicidal ideation among residents and work backward for solutions.
“I call it the ‘paradise paradox,’” said Jennifer McAtamney, Building Hope’s executive director. “People come to the mountains running away from problems, some they might not realize are deeply buried inside. They get here, and it’s beautiful, but it’s so hard to live here.”
McAtamney pointed to the most common stresses in Summit, such as the high cost of housing that can take up more than half of an individual’s income, which necessitates multiple jobs and little time to take advantage of the outdoor playground and other perks of living in a ski resort community.
“Then winter rolls around, and it gets dark and cold, and they realize the paradise isn’t really that much of a paradise,” McAtamney said. “There’s a guilt where they come to a wonderful place and are not feeling better. The despair starts to snowball.”
Adding to the stress is the isolation of living in a rural mountain community, where people come and go frequently and meaningful social connections are hard to come by. To get people talking about mental health, as well as to help build meaningful social connections, Building Hope has events geared toward bringing people together over common interests and hobbies.
To alleviate the cost of mental health care, Building Hope also grants scholarships that pay for 12 therapy sessions. Building Hope has issued more than 700 scholarships to pay for professional help that people otherwise might not be able afford.
The Summit Community Care Clinic, which accepts Building Hope scholarships, has two trauma-trained therapists on-site with 13 providers in total. Every patient who goes to the clinic receives a universal screening for mental health and substance abuse issues. The clinic provides these services to the public regardless of insurance status or ability to pay.
The clinic also provides counselors or therapists for students at all Summit School District schools, where clinic CEO Helen Royal sees the most urgent need for mental health services. The clinic is expanding its offerings at its school based health centers, getting a boost from last year’s voter-passed Stronger Future ballot initiative that will provide $20 million for mental health and suicide prevention programs over the next 10 years.
“Kids these days have such a higher acuity on life, and that comes with higher suicidality and complex needs,” Royal said. “We’re really trying to do earlier interventions so they don’t have to spend a lifetime struggling.”
Mind Springs Health, the Western Slope’s largest private mental health care provider, also operates in Summit County. Dr. Jules Rosen — the former chief medical officer of Mind Springs, who currently works as an independent consultant — revolutionized a phase-based care model that has improved outcomes and cut wait times for patients experiencing depression and anxiety in Summit and other communities west of the Continental Divide.
The model uses a committee approach to each patient to assess their needs and use the best treatment approach, such as group therapy or medication, rather than relying on a standard model that has every patient seeing a therapist for weeks, even if it is not required. That also frees up resources to help more people more quickly.
When it comes to preventing suicide, Rosen said it is critical that we study and try to understand the individual cases of suicide and suicide attempts in Summit to see what, if anything, makes them unique.
“We won’t know how to help without understanding who these people are,” Rosen said. “We have a very different pattern in the mountains from the national one. Nationally, elderly white men have the highest prevalence, but that’s different in the mountains. We need to know who they are and what are their risk factors. Without understanding risk factors, we don’t know where to intervene.”
Law enforcement’s role
Aside from health care providers, another critical link in the mental health chain is law enforcement, which regularly handles calls involving people experiencing a mental health crisis or expressing suicidal ideation.
A top priority for Summit County Sheriff Jaime FitzSimons has been making an appropriate response to calls involving mental health.
“If you dig down below the surface of any call for service, you’ll find some kind of nexus to mental health or substance abuse,” FitzSimons said.
FitzSimons said he has seen mental health as a woefully under addressed problem in his three decades in law enforcement. During his time in Summit, he’s noted common patterns in the people his office arrests.
“I walk my jail every single day and talk to inmates, ask them how they’re doing and where they’re from,” FitzSimons said. “A lot of people say they came here, blow through whatever money they have, and can’t find a place to live. They stop taking required medications, like psychiatry medications, and start self-medicating with marijuana or alcohol. They get into trouble, go to jail, which makes their mental state worse, and when they go out, they get back into the same cycle.”
FitzSimons soon will be getting a critical tool he has long seen as a way to help break the cycle. The sheriff’s office is recruiting and training a unit that pairs a law enforcement officer with a mental health clinician, called a Systemwide Mental Assessment Response Team, or SMART. The team will be available to all county law enforcement, including local police departments.
When the unit is established and deployed, the team will respond to mental health calls with a tag team approach, where the scene would be secured by the deputy or officer, who would then hand off to the clinician to evaluate and treat the patient. If the law enforcement officer is no longer needed, they will be freed up to respond to other calls.
FitzSimons said mental health calls are often the most complex and time-consuming cases to work with, meaning the new unit will help conserve law enforcement resources along with putting people in a better place to heal, rather than a jail cell.
“This SMART unit will be a game changer for the community,” FitzSimons said. “It will help make people whole, to let them stay in the community and be successful contributing members of community.”
Even heroes need rescuing
As an adventurer whose exploits drop jaws and inspire other mountaineers to push their limits, Libecki gets why people might think he’s got it all “figured out.” But he’s the first to acknowledge he is as vulnerable to mental health troubles as anyone.
As a single dad to his 16-year-old daughter, Lilliana, he feels he carries a sacred responsibility to come home safe, even while continuing to go to the most isolated places on the planet.
To ensure the weight of the world doesn’t settle on his shoulders at the worst time during one of his climbs, Libecki feels it’s important to talk regularly about what’s on his mind and in his heart, and to have those expressions reflected off another person.
“Human connection is incredibly powerful,” Libecki said. “It’s something that is being compromised with technology and social media. I know that, for me, the social aspect of community provides the strongest moments and joy for my mental health.”
Whether it’s having deeply personal and therapeutic conversations with teammates in a wind-battered tent at the edge of a cliff at the end of the world, or talking to a professional therapist trained to listen and guide people to better mental health, Libecki considers talking about mental health an absolutely critical part of the human experience, one he doesn’t want people to miss.
“I encourage anyone to see a therapist, especially in today’s day of social media where it’s hard to disconnect,” Libecki said. “Go see a therapist, go talk to someone. Even if you feel like you’re fine. I’m an advocate of promoting better mental health, including with this lifestyle. I climb and travel the world. It’s an incredible life, but one that has major compromise and sacrifice that can bring tough times with it. I know that, more than anything, nothing is more important than our mental health.”
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