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Suicide rates are on the rise, a public health issue with complex roots
Keene Sentinel - 6/15/2018
June 15--As the nation processed the news of chef and TV personality Anthony Bourdain's and designer Kate Spade's suicides last week, the Centers for Disease Control and Prevention released new data showing that suicide rates rose in almost every state over the past 17 years.
At nearly 50 percent, New Hampshire's rate increase stands at the top, second only to Vermont and North Dakota.
And Cheshire County isn't immune, as recent obituaries and the death last year of a beloved local law enforcement official help to illustrate.
A 2013 report by the state's Suicide Prevention Council notes that a yearly breakdown of county-by-county suicide rates is too small to know if they're growing regionally.
But data from the New Hampshire medical examiner tallied 18 deaths by suicide in Cheshire County last year and 12 in 2016. For each person who died this way, many others have told a social service agency or the police that they have thought of taking their life.
Keene police responded to 107 calls from people contemplating or attempting suicide last year. As of Monday, the agency had responded to 35 such calls since January.
The Samaritans of Keene, an organization that runs a suicide hotline, receives an average of three crisis calls a day, according to Executive Director Carmen Trafton. She said the hotline got about 1,700 calls last year.
"At first glance, it's hard to understand how something like that could happen in New Hampshire," said Gary Barnes, executive and clinical director of Maps Counseling Services, an agency with locations in Keene and Peterborough that provides mental health counseling. Granite Staters, he noted, enjoy a relatively high quality of life, with fairly low rates of poverty and crime.
But suicide is a public health issue with complex roots, he said. Rising suicide rates in New Hampshire coincide with the spike in opioid misuse and the decline in mental health beds across the state, according to Barnes.
Addiction, he said, often occurs in concert with depression and anxiety, and the lack of mental health resources can deepen a mental health crisis, leading people to consider suicide as an option.
The CDC's report likewise points to a connection between substance misuse and suicide. Almost 30 percent of people who died by suicide in 2015 had a history of drug use or had sought treatment in a rehab facility before their death. The report also cites other contributing factors, including relationship problems, financial hardship, a recent crisis and the availability of firearms.
"It is always alarming to see it in black and white," said Patricia Tilley, deputy director of the N.H. Division of Public Health Services, of the CDC report. "And we know it's complicated. Folks who die by suicide often are not known to have a diagnosed mental health condition at the time of their death. Sometimes they do, but often times they don't."
When Cheshire Medical Center closed its psychiatric unit in 2016, the county lost 12 beds for adults and six beds for adolescents in crisis. Peter Starkey, executive director of Monadnock Area Peer Support Agency, said the loss of this capacity was a blow to the mental health community. The Dartmouth-Hitchcock affiliate closed its unit because it wasn't able to recruit enough psychiatrists to staff it, according to a 2016 news release from the hospital.
Sara Gilbert, a psychiatric nurse practitioner at Cheshire Medical Center, said more people are coming to the emergency department with suicidal thoughts compared to a decade ago.
Cheshire Medical Center's behavioral health team, which Gilbert oversees with a psychiatrist and includes another nurse practitioner, works to stabilize patients at the emergency department and refer them to appropriate resources, including outpatient services, the state hospital in Concord or to inpatient beds in Vermont and Massachusetts. When patients need to go to the state hospital, wait times may be longer.
As of Thursday, 48 adults were waiting in emergency departments across the state for beds at the New Hampshire Hospital, according to the state's Department of Health and Human Services.
"We do our best to treat patients while they are waiting in the ER and restart them on medications or start them on medications," Gilbert said, "provide support to them, keep them advised of what the plan is, help facilitate them to develop coping skills, work with them on depression management, anxiety management while they are waiting for a bed."
She said the behavioral health team is not a substitute for the inpatient psychiatric services the mental health unit provided.
But even in the unit's absence, hospitalization should be a last resort, not a first option for mental health treatment, according to Gilbert.
Chronic diseases such as diabetes, she noted, are treated primarily through outpatient services -- through early diagnosis, medication and other supports. Mental health should be treated similarly, she said, with emphasis on crisis prevention in an outpatient setting. But a lack of outpatient clinicians, such as psychiatrists, can land people who could have been treated as outpatients in the emergency department.
"We treat mental health where it's more in a crisis phase (than) in prevention," she said. "We put a lot of resources towards the crisis phase and (don't) mention early identification (and) treatment like we do with other medical problems."
The Monadnock Area Peer Support Agency now operates the only two mental health beds in the county, where people in crisis can go for a short time to be supported by their peers, Starkey said, and these non-clinical beds are full 50 to 60 percent of the time.
He said about a third of the people who use these beds have thought of suicide.
"When someone is contemplating suicide, that's a tool they are thinking about," he said. "And it's a tool that means that they don't think there's anything else for them to use."
At the peer support agency, people who have experienced depression and suicidal thoughts support each other, according to Starkey, but the level of care the Monadnock Area Peer Support Agency can offer isn't suitable for everyone. The state needs more transitional facilities, more acute care beds and more therapists, he said.
Meanwhile, access to mental health care is only part of the problem, according to Philip Wyzik, chief executive officer at Monadnock Family Services. Too often, he said, people who contemplate suicide don't seek help because of the stigma.
Wyzik's observation is borne out in the CDC's findings. Almost 55 percent of those who died by suicide in 2015 did not have known mental health conditions, according to the report, which used data from 27 states for the figure.
Monadnock Family Services, which has offices in Keene and Peterborough, operates a 24/7 support service and often responds to patients with mental health crises in the Emergency Department.
'Before a crisis comes'
Corynne Letendre remembers how desperate she felt. By the time she attempted suicide three years ago, she had been talking about it for more than a decade. The Hinsdale resident, now 25, had lost her mother weeks before, but it was the suicide of actor and comedian Robin Williams that pushed her over the edge. By that point, she had been in and out of hospitals.
Hospitalization helped keep her safe in the moment.
"But it doesn't help the underlying problem," she said. "A week in a hospital does not teach you how to want your life again."
It wasn't until she found help through Monadnock Area Peer Support that she found relief, she said. Letendre, who now works at the agency, said talking about her experience with people who have been through it has helped her. Peer support helps her manage her feelings and the suicidal thoughts.
"Mental health needs to not only be in hospitals and therapists' offices; mental health needs to be at home and with your friends," she said.
The state's Suicide Prevention Council also emphasizes the need for community involvement to prevent suicides. In its 2017-20 strategic plan, which was published in 2016, the council noted that strategies such as promoting social support and enhancing people's life skills are needed alongside increased access to mental health services.
Tilley, of the state's public health services division, who is also a member of the council, said prevention efforts should encompass everyone.
"Preventing suicide requires everyone in our community to play their part," she said. "There's a role for government; there's a role for ensuring there's safety net services available.
"There are also roles within communities for faith-based providers," she said, "there are roles for community-based providers, there are roles in our community among our family and friends to ensure that people in our community are feeling connected personally and are connected to resources that do exist before a crisis comes."
Liora Engel-Smith can be reached at 352-1234, extension 1439, or email@example.com. Follow her on Twitter @LEngelSmithKS.
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