Tailoring Outreach to Prevent Suicide

For Ammon Love, a minor fender bender en route to the gun store in 2020 might have provided the lifesaving pause that he needed. (2022)

(Direct link to the article here.)

By Charlotte Huff

Avery withdrew from those around him the summer before his sophomore year, and family members tried to figure out what was bothering him without success, says his mother, Shari Elliott. But they didn’t realize that the fifteen-year-old had access to a gun, his hunting rifle. Last they heard, he had loaned it out to a friend headed out on a camping trip.

Avery, who was staying at his father’s house that July night in 2013, was found shortly after dinner. “He was gone that evening, that night,” says Elliott, who lives south of Salt Lake City, Utah. “His dad had no idea that he had the firearm.”

In the years since, Elliott has gotten involved in suicide prevention efforts, including fundraising walks. She has strived to focus on Avery’s life, his love of camping and fishing, his ability to quote episodes of The Simpsons. She tries not to dwell on hindsight. What if they had known how truly troubled their son was? What if they had made sure that his rifle had been locked away until the worst of his crisis had passed?

“We thought maybe something was going on, but he wasn’t willing to talk about it,” Elliott says. “Never in a million years would we have thought,” she pauses, her voice cracking slightly, “that he would have done this.”

But frank conversations about suicide, and ways to prevent it, were more muted nine years ago when Avery died, even as the US suicide rate continued to rise, especially in mountain states. Although Utah, founded by Mormon pioneers, is widely known for its sparkling lakes, national parks, and clean living, with the nation’s lowest smoking rate, the state also has been shadowed for years by suicide. In 2019 Utah ranked sixth nationally in suicide, with 654 deaths, or a rate of 21.2 deaths per 100,000 residents, according to the most recent Centers for Disease Control and Prevention (CDC) data.

Over nearly a decade, particularly in the past five years, clinicians, public health leaders, state legislators, and others across Utah have coalesced in an effort to turn the tragic tide.

Intermountain Healthcare, the state’s largest health system and employer, has constituted one cornerstone of these efforts, making screening for suicidal thoughts more routine, including at annual checkups. The health system has opened three behavioral health access centers in Utah, with a fourth slated to open in 2022, to provide an area separate from the emergency department with clinicians trained in mental health crises. Intermountain Healthcare also created a mental health crisis hotline shortly after the start of the COVID-19 pandemic. These steps have occurred alongside other suicide prevention efforts on multiple other levels statewide, including the passage of legislation requiring schools to implement suicide prevention strategies as well as the expansion of mental health and crisis support services. Meanwhile, a high-profile suicide prevention campaign called Live On has highlighted prevention resources for community members, including targeting specific populations, such as with a Spanish-language campaign launched in 2021 to reach the state’s growing Latino population.

The state’s ambitious goal, set in a 2017 report by the Utah Suicide Prevention Coalition, was to reduce suicide rates 10 percent by 2021. A big educational focus, through Live On and other efforts, has been to reassure people that they won’t plant the idea of suicide in someone’s mind by simply asking whether they are considering harming themselves, says Taryn Hiatt, Utah/Nevada area director of the American Foundation for Suicide Prevention.

“That’s been a myth we’ve been trying to dispel for years,” Hiatt says. “Asking gives permission for people to instead talk openly. The silence is what’s kept so many people from reaching out or help seeking—because they haven’t known who they could talk to.”

Utah’s efforts, including education about gun safety and gun locks, also build on accumulating research that shows that the worst of a suicidal crisis can be quite short. People often deliberate just a few hours, and sometimes even less than half an hour, before making an attempt, according to a review of study findings compiled by the Harvard T. H. Chan School of Public Health.

For Ammon Love, a minor fender bender en route to the gun store in 2020 might have provided the lifesaving pause that he needed. When a police officer asked if he was OK, he began to cry. “I sat there for a long time on that grassy hill next to where the accident happened,” the twenty-nine-year-old says in recalling the incident. “That gave me the breathing room I needed, to be honest with you. It gave me the space to not actually go buy a gun.”

At Intermountain Healthcare, leaders describe their suicide efforts as part of a broader commitment to better meeting their patients’ mental health needs, as well as to participate in public health prevention more broadly. Lisa Nichols, an assistant vice president of community health, also details how a bit of a cultural shift has occurred among clinicians in recent years as researchers have learned more about suicide.

No longer, she says, do clinicians start from such a helpless vantage point—that suicides are inevitable, that they cannot be averted. Through training, Intermountain Healthcare teaches all of its staffers, from doctors and nurses to receptionists and security guards, to watch out for vulnerable people so that they can be referred for treatment. Although no one should be blamed if a death does occur, Nichols says, “the truth is that there is much that can be done, and suicide can be prevented.”

“There are ways to assess and screen and keep people safe and get them into care,” she continues. “And we know that most people who contemplate suicide don’t go on to make another attempt at suicide and are really delighted that they continue to live.”

‘More Engaged’

Utah sits among a stretch of Mountain West states, sometimes dubbed the suicide belt, that have watched their chronically high suicide rate rise even higher during the past decade. In 2005 Utah’s rate of suicide deaths was 15.4 for every 100,000 residents, ranking it ninth in the US according to CDC data. By 2015 Utah ranked fifth nationally, with a rate of 22.4 deaths per 100,000 residents.

During a similar stretch, from 2011 to 2015, suicides among Utah adolescents ages 10–17 jumped, going up 136.0 percent compared with 23.5 percent among US adolescents, according to a report prepared by CDC researchers for the Utah Department of Health in 2017. Although suicide then and now remains far more common among middle-aged men, those worrisome adolescent trends led to the creation of a youth suicide task force by Gary Herbert, then governor of Utah, and galvanized other players to devote more time to prevention, Hiatt says. “Youth definitely got the discussion happening and motivated people to be more engaged.”

In the US, the states with the highest rates of gun ownership largely overlap with the states with high rates of suicides, says Kim Myers, suicide prevention coordinator and assistant director of adult mental health at the Utah Department of Human Services. It’s not that gun owners are any more likely to be suicidal, Myers says, but “they are more likely to die if they use a firearm as a means to take their life.”

Myers, whose suicide prevention role was created in 2013, credits a push starting about that time to counteract the state’s perennially high and rising suicide rate, driven by public health groups such as the state’s National Alliance on Mental Illness organization and other leaders. The emerging efforts garnered a legislative champion early on in Utah state Rep. Steve Eliason after several teen suicides occurred in his community, she says. Eliason and other state legislators have authored numerous bills since, but one of the early linchpins in prevention efforts stemmed from 2016 legislation requiring a study to look at suicides and firearms data.

The resulting report, published in 2018 by Harvard researchers, found that in Utah 85 percent of all firearms-related deaths during 2006–15 were suicides. Among suicides specifically, half of deaths involved a gun.

Another common influence runs through residents of the western US: a brand of individualistic, pull-yourself-up-by-your-bootstraps ethos, as Myers describes it. “In Utah specifically you have this pioneer history,” she says. “This idea that they came to the plains and settled in this harsh landscape.”

That figure-it-out mindset is helpful “if you are a pioneer,” Myers says. “It’s not helpful if you have a brain illness.”

‘Everything Changes’

For Love, as he reflects on the worst day of his life, the tensions had been building for several months. In February 2020 Love realized that his marriage was on shaky ground. Then the US shut down amid the early days of the pandemic—and with it, Love’s work as a wedding videographer. He had been booked six months out, but now people wanted their deposits back.

Love dug into his savings, trying to pay back about $40,000 in deposits. He was going into debt, teetering on the brink of bankruptcy, even as he realized that his marriage wasn’t going to make it. Increasingly, he had recurring images involving guns. “I kept envisioning getting rid of the pain,” he says. “Just stop the pain. Just make me not care, was a lot of my prayers. Just take these intense feelings away.”

One day in May he got in his car and headed toward the gun store, so distraught that he ended up bumping into the back of the car in front of him. When the police officer arrived, he says, “I probably looked like a wreck. He asked a very pointed question about how I was doing. I kind of start[ed] crying.”

That time sitting on the hill, Love says, was pivotal: “Sitting there and thinking, ‘How did I get here?’"

Nearly half of all Utah homes have at least one firearm, and in some rural counties ownership can approach three-fourths or even more of all homes, according to a Utah Department of Health report on firearms deaths published in 2020. The majority, 84.1 percent, of firearms-related deaths in Utah during 2014–18 were the result of suicide, and 11.2 percent were intended homicides, the same report found.

Clark Aposhian recalls first hearing similar figures almost a decade ago when he was invited to join a small group for lunch, a gathering that included Eliason. Aposhian, who chairs the Utah Shooting Sports Council, the state’s leading gun rights organization, had never heard that suicide figured in more than two-thirds of the state’s gun deaths. But when he scrutinized the numbers further, they checked out.

In the years since, the sports council has identified areas of common ground with more wonky public health folks by focusing on promoting gun safety, including passing out gun locks at gun shows and other events. Statewide more than 200,000 locks had been distributed as of June 2021 through efforts by the sports council, Intermountain Healthcare, and other public and nonprofit health entities, according to Myers.

Firearms owners can be a tough sell, says Aposhian, who incorporates gun safety and suicide prevention into concealed carry permit and other classes that he teaches. For instance, they may insist that they don’t need to lock up their guns because they have taught their children to handle guns safely.

Aposhian’s response: You have raised your kids well, so they won’t unintentionally hurt anyone. “The difference with suicide is completely different, it’s when they are intending to cause harm to themselves,” he reports telling them. “We have to explain to them that everything changes when they are in crisis.”

Owners also can be resistant to locking away their gun if they purchased it to guard against a home invasion, says Rowdy Reeve, who owns a shooting range in St. George, Utah, and who got involved with prevention efforts after a suicide shortly after that range opened. But modern technology now offers a solution, as bedside gun safes can be programmed to quickly open with someone’s fingerprint, he says.

Reeve also asks gun owners to weigh the relative risks in their own homes. “I say, ‘Think about where you live. How many times have you woken up in the middle of the night and somebody has been in your house that shouldn’t be? But if you have a kid, how many times has your kid come home worried about this or stressing about that or sad?’”

What’s notable about Utah’s efforts to promote gun safety is all of the diverse perspectives that have gathered, from mental health advocates to fierce gun proponents, says Catherine Barber, a senior researcher at Harvard’s Injury Control Research Center who was one of the authors of the 2018 report and of a 2019 Health Affairs article on the subject. And they haven’t given up but continue brainstorming ways over time to reach different populations, she says. “They’ve been treating it more as a winnable battle.”

It was Aposhian, she says, who suggested the idea for a public service announcement (PSA) that was particularly creative in reaching gun owners. The spot, which is posted on the Live On site, features a man pausing at a gun range and describing how some friends had stopped by the prior year when he struggled with depression and offered to temporarily hold onto his guns. “I think they saved my life,” he tells the camera. The spot “hits so many good messages of recovery, of resilience, of a really nice ‘bro’ way to show that you care,” Barber says. “I haven’t seen a better PSA on suicide prevention.”

Aposhian readily admits that there’s a degree of self-interest in his group’s involvement. If the council had not gotten ahead of the curve, pushing for voluntary measures, he says, the growing public awareness of the link between suicides and guns could have resulted in more regulatory measures. Red-flag legislation, for example, allows for the confiscation of guns from people deemed dangerous by the courts. Aposhian would rather see voluntary measures, such as a bill he testified in support of during the most recent 2021 legislative session; the bill, which has since become law, allows people at risk for self-harm to temporarily put their names on a “no gun” list to prevent themselves from purchasing a weapon.

But Utah, despite encouraging legislative advances, remains “a gun-toting Second Amendment state,” says Hiatt. During the same 2021 session, she points out, another bill lifted the requirement to get a permit to carry a concealed firearm within Utah, which means that gun owners no longer have to take a course that includes suicide prevention and gun safety education.

‘A Call To Action’

At Intermountain Medical Center the shift had been a heartbreaking one, and it was only partially over. The woman had arrived at the emergency department of the hospital in Murray, Utah, after her cardiac arrest. She was thirty-five weeks pregnant. Physicians had performed an emergency cesarean section in the hopes of saving the baby. “A beautiful baby girl survived,” recalls Adam Balls, chair of the hospital’s emergency department. The mother did not.

Balls, who was already in the process of creating a peer mental health support program in the wake of a suicide by an emergency department coworker, noticed the demeanor of one of the physicians. She had just begun her shift, he says: “She was so distraught and upset by the emotions and challenges of that patient that I recognized that she couldn’t most likely keep working and be effective through the remainder of her eight-hour shift.”

Balls arranged for someone else to cover the physician’s shift so that she could head home. “She was very willing to go home,” he says. “She didn’t really think that that was an option. I think she felt like many of us do after these events occur—that ‘I’ve got to put on a good face. I’ve got to bottle it up. There are other patients who need me to take care of them.’”

As clinicians and other leaders at Intermountain Healthcare have expanded suicide prevention efforts for patients, they have also tried to be kinder to themselves, starting even before COVID-19 further strained clinicians’ resilience. In 2019 Balls and other emergency department colleagues launched the peer support program, training some emergency physicians and other staffers in suicide prevention so that they can assist struggling coworkers.

Intermountain Healthcare’s headquarters are located in Salt Lake City, and nearly all of its twenty-four hospitals are located in Utah. But the nonprofit health system operates more than 200 clinics and other health services across a swath of the Mountain West. When Intermountain Healthcare leaders analyzed preliminary internal suicide data from 2011 through 2014, they found that nearly one in four Intermountain Healthcare patients who had died by suicide had been seen by one of the system’s primary care providers within the week before their death, says Mark Foote, who recently stepped down as Intermountain Healthcare’s senior medical director for behavioral health services to focus on his psychiatry practice.

They asked themselves, as Foote recalls it, “‘What could we do to help alleviate some of the attempts and some of the deaths?’ That was really a call to action.”

In the wake of those findings, patients are now screened for signs of a depressed mood at least once annually during a primary care visit, Foote says. Those patients who score high on a two-question screen get a longer screening comprising nine questions. As of the fall of 2021 more than 400,000 primary care patients had gotten at least the initial screening in the prior twelve months, according to Foote.

Since 2017 three behavioral health access centers have opened, which serve essentially as psychiatric emergency departments, providing a soothing environment for people who don’t need hospitalization but a place to decompress and get help. “You don’t show up to a psychiatric emergency room or an emergency room with a behavioral health crisis,” Foote says, “unless it’s probably one of the worst days of your life.”

The establishment of the access centers has required up-front investment, funded by Intermountain Healthcare as well as philanthropic donations, Nichols says. The treatment setting is better for more than just distressed patients, says Tammer Attallah, executive clinical director of Intermountain Healthcare’s behavioral health clinical program: “Providing care in an emergency department at any point is much, much more expensive than to provide the same care in an access care center.” The lower costs associated with using access centers translates to lower bills for patients as well as for the health system, he notes. During more than four years, from February 2017 through September 2021, more than 26,000 patients had been seen at one of the access centers, according to data provided by Foote. When the pandemic flared in March 2020, the health system launched an emotional relief hotline that was initially for Intermountain Healthcare employees but has since been expanded into a behavioral health services navigation hotline open to anyone who calls, Foote says. “If you don’t know how to get engaged into the [mental health] system, you don’t,” he explains. “The idea is that we want to connect the person at the right time, with the right resources, right off the bat.”

Not Yet ‘Out Of The Woods’

Given the prominent role of the Church of Jesus Christ of Latter-day Saints (LDS) in the state—55 percent of Utahns identify as members of the church, according to a Pew Research Center study—there has been some discussion and debate about whether church teachings have isolated and strained the mental health of certain populations, such as those who identify as gay or transgender. The church, for instance, will not perform same-sex marriages.

“The church has been a bit of a target, maybe a little more than a bit of a target,” says Travis Baer, a member of the Utah Suicide Prevention Coalition and a licensed clinical social worker with family services at the Church of Jesus Christ of Latter-day Saints. But the church has played an active role in suicide prevention efforts, compiling videos and other educational materials online that provide resources and ways to help vulnerable loved ones, Baer says. In one 2018 video Elder Dale Renlund, one of the church’s most senior leaders, states that suicide doesn’t constitute a sin and that church members should reach out in love and caring to those struggling with suicidal thoughts.

“That was huge,” Hiatt says. “These LDS families, Mormon families, didn’t feel like you could talk about how your loved one died because people viewed it as a sin.”

Utah is well situated to gain better insights into the state’s suicide trends, including identifying potential risk factors, because its state legislature created the rare position of psychological autopsy examiner in the Office of the Medical Examiner. Michael Staley, the first to fill that post, has shouldered the daunting job of conducting lengthy interviews with friends and family members after someone dies of suicide to build a richly detailed database that reflects the individual’s life before their death.

Staley, who is openly gay, says that he has felt a bit on the hot seat amid discussions in media coverage about the potential influence of LDS teachings.

“That really ticked me off, frankly, when those first couple of articles came out early on,” Staley says. “Because they really pigeonholed my role as this person that was hired to either prove or crack the code of the intersection between religion and sexuality.”

To date, a link has not been established between religion, sexual orientation, gender identity, and suicide deaths in Utah, according to Staley. But neither can it yet be ruled out, he says, noting that they are just starting to analyze the mountain of data that they have collected. Broadly speaking across all populations, suicide risk—and thus the related prevention efforts—will likely involve multiple factors, he says.

To this day, Love counts his blessings that he was slowed down by that fender bender, his first accident in a dozen years. “It literally felt like an act of God,” he recalls. “It was so random. It was so fluky.”

He never went to the gun store and later called the crisis hotline number that the officer provided, along with seeking therapy. Love, who is Native American and a lifelong Utah resident, has returned to school, majoring in psychology at Salt Lake Community College. Next up for Love is the pursuit of an MD/PhD so that he can study the brain in pursuit of strategies to prevent suicide.

In recent years the state’s suicide prevention leaders may have gained traction. From 2017 to 2019 the suicide death rate declined by 6.6 percent, according to CDC data,² which is encouraging but not yet statistically significant, Myers notes.

But Staley counts himself among those who are warily watching for fallout from the nearly two-year-long pandemic. “I don’t think we’re out of the woods [in late 2021] for a lot of reasons,” he says. “If you look at other periods of social unrest—for example, the Great Recession of 2008—the increase in suicides didn’t come until later,” once the crisis had eased, he points out.

As Staley wraps up interviews with the loved ones of someone who has died, he will ask them how they are personally coping. It’s often the moment that tightly held emotions bubble to the surface. “Sometimes we encounter people who are in a lot of distress, who have lost their support system,” he reports.

With their permission, Staley will connect them to therapy and other resources, striving to avert even one of the roughly 650 Utah suicides that occur each year. “We know these people are at a higher risk of suicide themselves because they’ve lost somebody to suicide,” he says. “That right there is suicide prevention.”

If you are in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), or contact the Crisis Text Line by texting HOME to 741741 in the US or Canada.