Out of the Shadows, Part 2 | The spectrum of suicide: Routt County part of ‘suicide belt’ with above-average rate

Every day since then, Gretchen describes her life as “a living hell.”

Two and a half years later, she doesn’t have any answers as to why, and the pain of losing her soul mate remains unbearably sharp.

“It took people a long time to say, ‘Oh it’s just Gretchen now,’” she said.

Across the nation, middle-aged white men have the highest rate of suicide among any group, according to the American Foundation for Suicide Prevention. In 2017, white men made up almost 70% of suicide deaths in the U.S.

In Colorado from 2004 to 2020, the age group with the highest rate of suicide was 45- to 54-year-olds.

The rate of suicide for men in Colorado is more than three times higher than among women, “Yet males who died by suicide were less likely to be reported as having a current diagnosed mental health problem or having ever been treated for a mental health problem,” according to a new report on suicide from the Colorado Health Institute, a nonprofit established in 2002 to provide impartial health data, particularly related to the uninsured and the publicly insured. 

Nationwide, suicide rates increased 33% between 1999 and 2019, according to the U.S. Centers for Disease Control and Prevention. It is the 10th leading cause of death in the country.

While there was a slight decrease in suicides across the country in 2019, Colorado saw an increase in number of suicides, reporting 1,287 suicides in 2019, the highest number ever recorded in the state.

In Routt County, there were seven suicides recorded in 2015, four in 2016, none in 2017 and 2018, four in 2019 and seven in 2020, according to data from the Colorado Department of Public Health & Environment. Adjusted for 100,000 people, the suicide rate from 2000 to 2020 in Routt County was 20 suicides per 100,000 people, which is higher than the state’s rate of 18.62.

Colorado is part of a swath of the Mountain West region referred to as the “suicide belt” — states that have a persistently higher rate of suicide than the rest of the country.

And rural areas as well as those at higher elevations tend to have higher suicide rates than more densely populated parts of the state.

Suicide on a spectrum

Suicidal thoughts — or ideation — are far more common than most people realize, according to mental health care professionals.

“Suicidality exists on a continuum and frankly, we’re all on that continuum somewhere,” said licensed counselor Eric Beeson in an article, “I’m Not Always Very Attached to Being Alive,” by Anna Borges, a writer, editor and mental health advocate who previously served as a senior editor and writer for BuzzFeed.

“Some of us are just closer to an actual suicide death than others,” Beeson continued. “But in many ways, we’re all a few life experiences away from a major mental health crisis whether we like to admit it or not.”

Molly Lotz, licensed clinical social worker and crisis support counselor at UCHealth Yampa Valley Medical Center in Steamboat Springs, would like to see a major shift in the way people talk about suicide and a normalization of suicidal feelings.

“Suicide should be looked at more as a spectrum of intensity rather than an on or off switch,” Lotz said.

When Lotz talks with her patients, or people concerned about loved ones, she references a scale of 1 to 10.

There are people at a zero — those who would never consider suicide as an option, Lotz said, but then there are a “huge amount” of people who may live every day at a two or three — where they aren’t making plans, but it is an option that “is always on the menu.”

“Thoughts about suicide are more common than people are aware of,” echoed Lilia Luna, behavioral health director and licensed behavioral psychologist for Northwest Colorado Health. “It’s important that people know thoughts about suicide are normal and common, so we can have that further conversation.”

From that conversation comes a well-defined process of assessing risk and creating a safety plan. But that initial conversation does not necessarily have to set off major alarm bells, depending on where someone is at on the spectrum, Luna said. It can just be a conversation.

In the event someone is deemed not safe, Luna said, the next level of care will be evaluated. And she stressed the importance of having access to that professional support.

As a state, Colorado has a higher prevalence of mental health issues and lower rates of access to care, with an overall ranking of 47th in the nation, according to Mental Health America’s 2021 State of Mental Health in America report.

While severe depression and other mental health disorders are some of the most common contributors to suicide, according to West Springs Hospital Medical Director Dr. Frank Lotrich, “You don’t have to have a mental health disorder to contemplate or complete a suicide.”

Vincent Atchity, executive director of Mental Health Colorado, said in his experience, “There are many, many people who have moments  — or much longer periods of time — during which they aren’t sure they want to be alive anymore and think about what it would be like to die by suicide.”

But at an eight or higher on the intensity scale, Lotz said, people are actively making a plan to carry out a suicide attempt.

A two or three on the scale may be a “comfortable” place, Lotz noted, where people are not actively planning anything, but suicidal ideation is simply a part of how they operate day to day.

However, if “a series of events or a life event happens, they may find themselves going up on the scale,” she said. “They might be thinking about it more and more. It becomes more accessible and feels bigger in their brain, and it is taking up more space, at which time it is important to start tapping into support.”

Helping people identify where they are at on that scale and getting them back to a more comfortable level is something that resonates much better with patients and their loved ones than an on or off switch, Lotz said..

“It makes sense — makes them feel like they are not crazy,” she explained. “We need to start talking about it more, so when there is an increase in ideation, we know what we need to do to help them get back to a place that feels manageable.”

For many people, the conversation should be about how suicidal they are feeling at a given moment rather than whether or not they are having thoughts of suicide.

The ability to have a safe place in which to talk about suicide also fosters social connectivity — the lack of which is one of the biggest risk factors for suicide. It helps people feel less alone — with isolation being another significant risk factor.

“The willingness to listen is potentially lifesaving,” Atchity said.

If someone is climbing up the intensity scale, finding that connection doesn’t have to mean a therapist, Lotz noted. It can be a trusted friend. And the act of simply connecting to that friend and letting them know you are at an eight can bring you down to a six, she said.

Once people reach the upper end of the scale, connection, intervention and prevention become much harder. And in general, the effort of prevention is challenging and complicated.

For people who make the decision to die by suicide, the time and opportunity to intervene between that decision and the act is on average very limited, according to Atchity.

“People may not realize how suicidal ideation is not necessarily something that goes on for prolonged lengths of time,” he said. “It can instead lead to acting within a pretty short time frame. Attempting or completing a suicide is sometimes associated with acutely experiencing stress or distress or feeling trapped.”

A vast majority of people who make a suicide attempt do so within an hour of making the decision to attempt, Lotz said. 

“That gives us hardly any window to intervene,” she said.

Lotrich noted that some of the people most determined to end their lives are the hardest to identify. They don’t want anyone to stop them and thus may be assessed as not suicidal.

There also is a wide spectrum in terms of demographics and intent when it comes to suicide, and it is important to acknowledge just how vast that spectrum can be, Lotrich said.

Every suicide is different, especially when looking at a teen girl who is being bullied or a middle-aged man experiencing a crisis or an elderly person with chronic pain.

Regardless, suicide is preventable, Atchity emphasized.

“And we all have a role to play in suicide prevention,” he said. “It has to do with being attentive to one another and being direct.”

That involves taking remarks seriously, and “making direct inquiries about what peoples intentions are,” he said.

Many of the trainings available give instruction on how to respond to someone who makes a remark referencing suicide.

Even if those remarks are off hand, they should not go unchecked, Atchity said. And that check can be relatively light hearted.

“If someone off hand says ‘I should just end it all,’ say, ‘Oh — would you really do that?’” Athcity advised. “Have a conversation.”

The question of why?

Some suicides come with more warning signs than others.

“Everything was always fine,” Gretchen said, about the moments, days, weeks and years leading up to Marc’s death. “It was always fine until that night.”

Gretchen saw no signs, and since Marc’s death, she’s racked her brain for any kind of sign she missed, no matter how small.

“There was no depression on his part. He was a happy guy.”

Marc was an incredible athlete, she said, and an incredibly humble one. He could do anything, she said, and regularly won races while barely acknowledging he’d come in first.

“I thought he loved life. I thought we had the best life together.”

And other people loved Marc, too, she said. After his death, one ski instructor friend commented how Marc made everyone feel like he was their best friend.

Today, Gretchen acknowledges Marc must have been hurting, and she feels anger toward him for not telling anyone.

She has no note, and no answers.

“I will never get over this,” she said.

One thing she can do is encourage others to have an honest conversation about their mental health status.

“People need to have this conversation and have it many times — say, ‘how are you feeling? Check in with me. What’s your mental health like?’”

In telling her story, Gretchen hopes it reaches someone who is having thoughts of suicide, so that they might “really ponder it longer than an instant.”

She doesn’t want anyone to go through what she has gone and is going through.

Rob Ryg, coroner for Routt County, said in his experience responding to suicides, the majority of friends and families left behind feel shock and disbelief. They say they never could have imagined their loved ones would go to such an extreme measure.

“I always say that if these people could see the effect of what they’ve done to the people they love and who care about them, most of them wouldn’t do it,” Ryg said.

While suicides leave suffering in their wake, Luna notes many people take their life thinking they are improving the lives of others. In that state of mind, she said, “It is an act of benevolence — thinking they will be better off without me.“

As to the why, Lotz noted, “It’s not necessarily that people want to die. It’s just they are so tired they can’t keep holding on.”

“Ultimately, it’s feeling like there are not any other options, which can come from not having any support or having lost a lot of what we value in life,” Lotrich said.

Luna urges people to look at death by suicide as more than the moment of dying. 

“It’s complex like any death,” she said. “It doesn’t lie on just one moment of death.”

If pain starts to outweigh pleasure, and quality of life is diminished, death by suicide becomes more appealing, Luna said. 

A lack of connection or belonging or a lack of agency or ability to resolve difficulties can contribute to thoughts of suicide.

“At the core of it all is hopelessness and feeling like a burden,” Luna said.

But then there are also suicides like Marc’s, and some other recent high profile suicides of seemingly happy people with perfect lives.

There remains an element of existentialism to suicide.

As Gretchen knows, there are questions that will never be answered, including why.

Atchity said there may never be an answer to the “why” for some people. 

“That door opens to a really dark place — with no ostensible exit — to that place where turning off the lights is the only thing to do,” Atchity said. “And there are many more people who have that doorway inside them than we acknowledge.”

Looking back at history, since suicide rates were recorded in the early 1900s, there were two significant spikes, Atchity said, one on the verge of World War I, and the second during the Great Depression and the beginning of World War II.

“Other than that, it has been a steady rate,” Atchity said. “As an observer of the human phenomenon, suicide comes with the territory of being human. There are going to be suicides.”

While Atchity lauds zero suicide as a good public health goal, it is ultimately not a practical one. Given a study of human nature, some suicides are unpreventable, he acknowledged.

“To say every suicide is preventable is an unfair thing to say to survivors of loved ones,” Lotz said. “There are people who we just don’t catch and who don’t want us to catch them. That’s tricky. That’s hard on our hearts. We don’t feel like we can do anything in those situations.”

Risk factors for suicide

There is a wide range of risk factors for suicide indicated in the research, and Luna said history is the biggest indicator, Luna said. If a person has exhibited suicidal behavior or attempted it in the past, they are at a greater risk.

Other things shown to increase risk of suicide include a history of mood disorders; substance use; access to weapons; traumatic brain injuries; impulsivity; family history of suicide; financial stressors; events that cause shame, humiliation or despair; being a Native American or LGBTQ youth; having chronic physical pain; or being the victim of bullying or discrimination.

There is also an element of anger, “turned at one’s self or the world,” Lotrich said.

Ryg said he’s seen that anger reflected in the notes of some of the suicides to which he’s responded.

“While many of the stories focus on mental health as a risk factor, suicide is complex,” according to the Colorado Health Institute report. “Physical health challenges, lack of social supports, access to lethal methods and situational causes like loss of a job or loved one can also contribute to the risk.”

The rate of suicide attempts is higher for women, and the data points to the choice of less lethal methods as a contributing factor to that difference.

But locally, statewide and across the nation, far more men die by suicide than women.

“Men and women may also react differently in situations of despair, such as during unemployment or in reaction to a loss of a loved one or a relationship problem,” according to the Colorado Health Institute report. “In Colorado, men were more likely to die by methods that leave little time for intervention and are more likely to be fatal, such as firearms and hanging/suffocation.”

Atchity pointed to economic pressures impacting men differently and “failing financially when you are responsible for things and not able to fill that role.”

There’s also a loss of purpose and identity that can come after retirement.

“Men are notoriously slow to seek help or share their thoughts,” Atchity said. “That quiet desperation can lead men to attempt or complete suicide.”

Numerous studies have shown access to firearms as a significant risk factor for suicide.

According to new research out of Stanford University published in the New England Journal of Medicine, men who own handguns are eight times more likely to die by suicide than men who don’t own handguns, and women who own handguns are 35 times more likely to die by suicide than women who don’t.

“Suicide attempts are often impulsive acts, driven by transient life crises,” wrote the authors of the Stanford study. “Most attempts are not fatal, and most people who attempt suicide do not go on to die in a future suicide. Whether a suicide attempt is fatal depends heavily on the lethality of the method used — and firearms are extremely lethal. These facts focus attention on firearm access as a risk factor for suicide especially in the United States, which has a higher prevalence of civilian-owned firearms than any other country and one of the highest rates of suicide by firearm.”

Nationally, firearms are involved in 50.4% of suicides and 28.5% are due to hanging or suffocation.

From 2017 to 2020 in Routt County, eight of the 14 suicides were completed with a firearm.

There are a number of caveats to remember when looking at data related to suicide.

“As always, suicide is incredibly complex, and there will be no way to know for sure why a rate increased, decreased or stayed the same,” said Mindy Marriott, executive director of Reaching Everyone Preventing Suicide, or REPS.

“Taking one year in isolation and making conclusions from that is not recommended,” Marriott said, referring to the near doubling of suicides in Routt County during 2020. “But that does not take away from the impact the last year has had on our community.”

Because the state and national data for 2020 are not yet finalized, it is unclear at this time what impact the COVID-19 pandemic had on suicide rates.

Luna emphasizes remembering the complexity of what led to the suicide. Like a death due to a heart attack, there can be many, many contributing factors over a long period of time.

“The death is more than just the incident,” Luna said. “There is a story behind everything. One of the misconceptions is that suicide boils down to a choice, but it is so much more complex.”

Those who are left behind

The grieving process for those left behind is complex. In addition to the anguish of a traumatic death, there can be regret, anger, guilt, resentment and the painful question “What could I have done to prevent this?”

Gretchen must live with the last living memory of Marc being an argument about loading her bike into the van.

The couple didn’t argue often, and this was just a trivial one.

Nothing significant. Nothing that seemed possible of pushing him over the edge.

But the pain Gretchen feels is immense, knowing her last words to Marc were “just leave me alone.”

“I went upstairs and went to bed in a different room, and that’s the last time I saw him,” she said.

More than anything, Gretchen is sad and still in shock at how her life could change so drastically in an instant without any clear reason or warning.

The hours after Marc’s body was discovered were made even harder by an accusatory tone from some of the law enforcement who responded, Gretchen said.

When her despair was most raw, she felt a lack of compassion.

And Gretchen is mad — mostly mad at Marc for not telling her or anyone he was hurting. Mad that she isn’t any closer to answers as to why Marc took his own life.

And she gets mad at the small things — like when there’s something around the house only he knew how to fix. It was Marc who insisted on waxing her skis and changing her bike tires, and it was Marc who did most of the cooking.

Gretchen has sifted through all the things that seemed to be even remotely bothering Marc, and she comes up with only an ankle injury and frustration at not getting worker’s compensation. He had experienced a couple of head injuries in his life, she said, but was checked out by a doctor. He had only a minute level of alcohol in his blood when he died and no other substances.

The couple had financial stability. They had plans for the next day. They had plans for their retirement. They loved to do things together.

“He was a great husband. He was an amazing guy,” Gretchen said. “I will never know what was going through his head.”

Now, survival for Gretchen is a minute-to-minute process.

The pandemic hit her especially hard.

She didn’t work during the winter, as most of her clients cancelled their ski trips. She didn’t see many friends. Her empty house felt even emptier.

Gretchen didn’t sleep more than a couple hours a night for the first two years after Marc’s death.

And until Marc’s death, she herself never had thoughts of suicide.

Now, “There are parts of many days I don’t want to be here,” she said.

“I have been at a 10, but I am trying to persevere — to keep going,” she said. “Just because I will hurt too many people if I don’t.”

Gretchen truly doesn’t know what she’d do without her dog Eme, who follows her everywhere and is very protective. Without the dog and her therapist, “I wouldn’t be here,” Gretchen said.

“I don’t have any moments of peace. I’m not there yet. I have hope I will get there, but I’m not sure I will.”

Finding help and hope

Every single morning since Marc’s death, Gretchen has a friend who calls to check in on her.

For the first year after his death, a “gang of 14” friends made a schedule. They were each assigned one day every two weeks when they would check on Gretchen. Some were Marc’s close friends. 

“They were just wanting to be there,” she said. “To be there and make sure everything was OK.”

They stopped by to say hello, brought food, plowed her driveway or asked if she needed anything repaired.

“They made sure I was taken care of,” she said. “I can call up any of those guys, and they’d do anything for me. “

Gretchen can’t imagine leaving the community in which she and Marc were such an intrinsic part of for more than three decades.

And by talking about it, Gretchen hopes she can help just one other person who may be suffering silently like Marc.

The mental health care professionals agree that perhaps the biggest source of hope in the face of suicide comes from talking about it more.

“Our reluctance to talking about it is not helping anybody,” Atchity said.

Directly asking someone about suicide “creates the opportunity to vent out, and let off the steam that is going to kill them,” he said.

“If people are more freely able to talk about it, then the more people will be able to continue connecting in this way,” Lotz said. “That is hopeful to me, and I am seeing that happening.”

Luna tries to focus on life. Those life preservers, or protective factors, she said, are the things that make people want to live — want to choose life.

“If we focus on death, we get stuck in death,” Luna said. “If we can focus on life and hope and promoting life in people who might be struggling — we all struggle at different times — that’s where the meaningful action is.”

Gretchen’s life preservers right now are her dog, therapy, and her friends and community. Other things, like a memorial to Marc funded by one of their longtime ski clients and a fund in Marc’s name set up for trial maintenance, give her something that feels positive.

And she wants to make a difference in the lives of others by telling her story.

“If Marc can die by suicide, anyone can,” Gretchen said. “That’s the way I look at it now. And that’s why I’m saying to people — everyone needs to have the conversation and ask ‘How are you feeling?’ and check in with each other.”

Locally, REPS sponsors a number of programs aimed at educating people about suicide prevention and providing support to those who are struggling.

With a recent increase in funding, REPS now is able to provide five free counseling sessions to people who need it — and not just those who are experiencing suicidal ideation.

“This has a significant impact on the health and wellbeing of our community and can potentially save lives, because we are able to connect people with crisis support before they are even in a place where they are contemplating suicide,” Marriott said.

REPS also runs a youth support group, education programs in the local schools and a program that provides advocates for people who attempt suicide or are experiencing a crisis.

Suicide is messy, complex and uncomfortable. But it is also very human. And there are few people whose lives have not been touched, if not profoundly impacted, by suicide.

Because suicide remains taboo in society, people in need of support are less likely to reach out and less likely to get the help they need, especially men.

They may not realize there are many people out there experiencing the same thing and finding a way through it.

“Awareness is a cause for hope,” Atchity said. “The more of us that have eyes on each other and can make direct inquires into what someone is intending to do — that’s the best level of protection we’ve got.”