A silent sorrow: Rural Colorado’s high suicide rate, and what’s driving it

Editor’s note: This is the first of two parts. Coming tomorrow: Youth suicide in Colorado, and how one rural Colorado county is working to combat it

A comfy chair — Christie Henderson remembers that. The therapist she’d finally gone to for help had her sit in an overstuffed chair. Her memory seizes on that specific detail in what is otherwise lost to the blur of time and the overwhelming despair that drove her to that therapist and that chair more than a decade ago.

Henderson remembers believing she had lost all her friends. She remembers believing, not for the first time, that she had nothing to live for.

Henderson, then 31, had long suffered from depression and, later, was diagnosed with bipolar disorder. In high school and college, she tried to mask her depression with alcohol, cocaine or prescribed medicines. When she moved from the East Coast to Basalt, a mountain town of 4,000 outside of Aspen, she believed the sheer magnificence of the Pitkin County landscape would “solve it all.”

It did not.

Earlier that year, she had attempted suicide. In the therapist’s office, Henderson’s pain was again unbearable to the point of immobilizing. And so there is one more thing she remembers about that day: that this small mountain town could not offer her the mental health care she needed. She asked her therapist if she needed to move to Denver for help. Yes, the therapist said.

“I just left, being like, ‘Okay, I’m moving to Denver,’ and didn’t really want to. But I guess I still had a glimpse of wanting to live.”

Along with other Rocky Mountain states, Colorado’s suicide rate ranks among the top in the nation. In 2016, Colorado saw a record 1,156 suicides — the ninth highest per capita rate in the country — more deaths than from homicide, motor vehicle crashes or breast cancer.

But there’s a big divide in Colorado, mirroring a national trend: suicide rates in rural and “frontier” counties regularly exceed those of urban areas. (Frontier is the state’s term for the least populated counties; the designation means mental health providers generally receive bigger financial incentives to work there.)

Colorado’s southwest corner and central mountains had the highest suicide rates last year, followed by a handful of eastern plains counties. Montezuma, La Plata and Archuleta counties in the southwest saw over 32 deaths per 100,000 people — compared with 18 per capita in Denver County — in 2017.

Geographical isolation, greater access to guns, and stigmas around mental health all contribute to Colorado’s high rate, experts believe. However, the state’s rural areas have one fundamental and unique challenge: access to mental health services.

For moments of crisis, there are local, state and national hotlines; however, suicidally depressed individuals also need access to mobile crisis units and walk-in crisis centers. If they are extreme threats to themselves, they need three-day inpatient care or hospitalization. It can take up to five hours a week, over multiple visits to the provider, to pull someone away from the edge of suicide, according to Mind Springs Health, the provider for most of the Western Slope.

For rural residents, this frequent and intense care is a challenge — their provider is often 30 minutes to three hours away by car, or it’s understaffed, leading to waitlists. Or the services aren’t available at all.

Two-thirds of the mental health facilities in Colorado are concentrated in urban areas; the remaining third serve 73 percent of Colorado’s geographic area, according to a Colorado Independent analysis of federal Substance Abuse and Mental Health Services Administration data. Eleven counties have no psychiatric walk-in crisis centers or hospitals.

Twenty-two rural counties do not have a licensed psychologist. In 2018, nine of the 10 counties with the fewest providers are rural, where there are over 2,000 patients per provider. The worst is Conejos, in extreme southern Colorado, with one provider to 8,130 patients.

Private providers fill in some gaps, but a 50-minute session costs between $50 and $500. Many don’t take Medicare or Medicaid, and few offer sliding scale payment options. Instead, patients generally use private insurance or pay in cash.

Other services common in urban areas aren’t available in rural ones. Forty of Colorado’s 47 sparsely populated counties offer crisis-intervention-team and suicide-prevention services, according to the 2018 federal Substance Abuse and Mental Health Services Administration provider survey. But fewer than 23 offer peer support, Spanish, deaf and hard-of-hearing services, or facilities with mental health and primary care in the same building — and those services are often available from just one health care provider in the county.

Not all of Colorado’s providers registered with SAMHSA, but the survey data in the map below shows how mental health services are distributed around the state.

This lack of access keeps many rural Coloradans, already struggling with severe depression and suicidal thoughts, from getting the care they need.

“It’s excruciating pain, and nothing seems beautiful to you,” Henderson said. “All you can feel is pain mentally, physically … it’s consuming.”

The pain affects people in every Colorado community. In rural areas, it’s men working in construction, agriculture, forestry, fishing and hunting, or not working at all, who are most at risk — often taking their lives because of depression, issues with intimate relationships or problems with alcohol, according to the state’s suicide dashboard. Across the state, white men between the ages of 25 and 54 are most likely to die by suicide, half the time involving a gun — although national trends show that women are more likely to attempt it.

In ski and mountain areas, those at risk for suicide tend to be low-wage retail and construction workers under great financial stress, away from family and social networks, who may feel despondent when they discover moving to an idyllic mountain setting doesn’t fix their problems.

That was certainly Christie Henderson’s case. “You want to live, but you want to die because it just … it won’t go away,” she said.

Maranda Miller’s job is to protect the suicidal, but most of her time is spent on the road.

As the suicide prevention services program coordinator for Centennial Mental Health Center in northeastern Colorado, she crisscrosses 10 counties, or 17,624 square miles, providing trainings and services to rural communities.

Patients face similar treks. “Out here, it can take two to three hours in a car to get to mental health services,” she said. Miller lives in Sterling, a town of about 14,000 people in Logan County and the main hub of Centennial’s 11 offices.

In Miller’s vast territory, houses and towns are far away from each other, and inhabitants can feel isolated and lonely. Agriculture can be strenuous, hazardous and financially stressful. Access to firearms and pesticides is easy.

Miller sees women who lose husbands, then find themselves raising kids and providing for their families alone; men, struggling through job loss or relationship issues, who decide to take their lives; kids who’ve lost fathers, and, she hopes, are getting the mental health care they need.

Rural communities also have a streak of rugged individualism that makes seeking out services a last resort. “We’re pretty resilient people in the rural areas, and pretty resourceful,” Miller said. “I think that’s a big part of [the challenge] too … still maintaining that, but teaching our kids, when they need help to reach out as soon as you can.”

Centennial is the only mental health care provider for nine of the 10 counties it serves, according to SAMHSA data. Last year in those 10 counties, 26 people took their lives, Miller said. Of the 85 clinical employees trying to serve 111,000 people in 2017, only one was a psychologist, 11 were mental health counselors and three were medical doctors, according to Centennial’s 2016-2017 annual report.

‘Nobody deserves to suffer like that’

Miller leads Centennial’s five-person suicide prevention team, which conducts suicide prevention trainings at businesses, fire departments, schools and other community organizations.

Miller stresses the importance of learning the symptoms of mental distress and

getting help before those symptoms reach a critical point.

“It’s like when you get that first little pain … you’re like, ‘I got this, it’s going to go away,’” she said. But often people make concessions for the pain, and gradually their quality of life starts to deteriorate. “It doesn’t have to be that way — nobody deserves to suffer like that.”

A year ago, the prevention team didn’t exist — it was just Miller, who ran the program mostly by herself for 13 years. That meant working long hours or seven-day weeks — the type of increased workloads and longer shifts characteristic of areas with health professional shortages.

Shortages mean clients often have to wait for services, which can discourage those most in need, Miller said.

“People know that it’s going to be a little bit of a wait, and that can be overwhelming, too,” she said. Some mental health providers commute into rural offices a few days a week, which means fewer options between therapists and more difficulty seeing one therapist consistently. “One thing we do know, it’s all about relationships, and one psychologist might not work for everyone.”

Many people struggle to find the right treatment plan or therapist. One in five patients with mood disorders, such as depression, drops out of therapy before completing treatment.

For Christie Henderson, finding that relationship was one of the biggest challenges in fighting her depression.

For years, she saw psychiatrists whose treatment plans consisted largely of prescribing her pills. When she sought treatment on the East Coast, she didn’t feel it was focused on the person’s needs. “It was more just like, this is what you have, this is what you do,” she said.

Moving from Basalt to Denver during that dark period in 2007 wasn’t Henderson’s answer, either. She soon returned to the Roaring Fork Valley, and upon the advice of a friend, went to the Aspen Hope Center, a crisis center that serves Pitkin, Eagle and Garfield counties. She said it saved her life.

This time, she sat on one couch while the therapist sat on another. 

“He said, ‘You know you’re not well.’ And I remember looking up and being like, ‘Wow, he’s talking to me like a human being.’ I’ll never forget that.”

Now, more than 10 years later, Henderson is the outreach coordinator for the center. Here, she shares her story and helps educate rural communities across three counties about suicide prevention.

“I think what it comes down to is educating the community,” she said. “If I was educated before what I went through, I think I would have had at least a clue in my mind to know there was help, and I didn’t even realize that.”

If you build it, they still might not come

Henderson and other suicide prevention trainers can’t always get the public to listen.

“I try to do suicide awareness classes, but it’s like the s-word — nobody likes it,” Henderson said, referring to suicide. “We have such poor attendance,”

People think that if they attend a class, others will think they’re suicidal or someone in their family is, she said. They don’t want others to think they’re weak or crazy for seeking help.

Along with access, stigma is one of the biggest barriers that keeps people who need care from getting it, say suicide prevention experts.

“It’s not always a situation of, if you build it, they will come,” said Sarah Brummet, director of the Colorado Office of Suicide Prevention.

Integrating mental health care with primary care is one way to combat the stigma issue. When doctors and psychologists are in the same building, patients can walk in the front door and no one who sees them knows what they’re there for, Miller said.

“Otherwise, someone might see your vehicle up front and wonder what’s going on,” she said. “Our offices are located across from McDonalds, and people speculate. I think it’s huge in our area just because the anonymity isn’t very high.”

Centennial is working on an integrated care plan, and Colorado has invested $65 million in integrated care initiatives across the state. Currently, only one facility in northeastern Colorado, Colorado Plains Medical, is integrated.

Another tool in the effort to reduce stigma is enlisting people outside the mental health care profession to engage with depressed individuals. “They can break that stigma down because they aren’t tied to a profession — they’re tied to relationships, and we know relationships are so important with suicide prevention,” Miller said.

Taking on the fight

Colorado needs to do two things to bring down its suicide rate: focus preventative care, and invest in suicide education and prevention until the rate drops significantly, according to the state Office of Suicide Prevention.

Part of the state’s strategy is to involve more providers, but also to pull other community members into the suicide-prevention education effort. And Colorado is already pursuing different ways of doing that.

For example, the Gun Shop Project, with partners in 21 counties, enlists firearm advocates, gun shops, firing ranges and more to educate people about suicide prevention. Sources of Strength, a peer-led, school-based suicide prevention training program, helps teens and preteens find hope and develop resilience.

These trainings are proven to be effective. Trainees became more confident and more likely to seek help or take action during a crisis. It’s this kind of preventative work that experts are relying on to help community members seek treatment before they reach a crisis level.

Colorado has been in the suicide prevention fight since the 1950s, and during that time, most of the funding has gone to youth programs, since suicide is a leading cause of death among people ages 10 to 24. The other group in most need is adult men, who last year accounted for 75 percent of Colorado’s 1,146 suicides.   

The state is working on all fronts to give these groups the resources they need, including focusing on men over the last five years through Man Therapy, which brings resources to men and decreases stigma through humor.

The three-person Office of Suicide Prevention, which gets $950,000 from the state’s general fund along with time-limited federal grants, is one group leading the charge for more funding.

“As a state and as a country, we haven’t invested to the amount where we could do comprehensive, multi-sector work,” said Brummet. “The state needs to invest more in suicide prevention to have an impact.” 

On the local level, organizations including Aspen Hope Center and facilities such as Centennial are always trying new ways to get suicide prevention resources to those in need.

In September, the Hope Center opened a new crisis center in Eagle County using funds from a 2017 marijuana sales tax — one of the first mental health-specific marijuana taxes in Colorado.

Henderson works around geographic challenges and stigma by using social media in addition to hosting events and attending community meetings. This way, if someone isn’t comfortable at or unable to attend a training, they still have access to information.

“One of our taglines is: We can talk. One conversation can save a life,” she said. “I want to do a campaign: One click can save a life.”

Starting in the spring, Miller will pull together a stakeholders group from the agriculture community who will meet quarterly to discuss ways to bring more resources and exposure to the suicide-prevention fight.

“I think a lot of people that run the sale barns and sell agriculture equipment probably don’t see themselves as a natural fit for suicide prevention, but they really are,” she said.

For those who are worried about someone in their community, experts have one piece of advice to start with: Ask them, “Are you thinking of killing or harming yourself?”

“For the person who wants to help, it’s better the more comfortable you feel with even asking the question,” Miller said. “It takes courage, I know it does — even not having all the answers — but being willing to help them research and find the resources they need.”

For anyone going through a dark time, Miller has a simple message: “There is hope for recovery … so have faith in the system and that people really do care. If someone asks, please do tell them.”