Though I disagreed with some of the arguments made in the film Believeras discussed in my previous post, it did help me to better appreciate how serious our problem with suicide is within the Utah, as well as all over the world, including right here in China where suicide remains a serious but often under-reported problem.

Speaking of suicides in China, I was just a few yards away from a tragic suicide, and would have been killed myself if I had stepped over into the path of a man who threw himself from the tall building where I work. It happened a few months ago where I work while I was casually reading a book one morning before work. He was only about 30, I think. It was a disturbing scene that strongly affected me for some time, and that was for a total stranger. On the same day, I received an even more disturbing image on my phone from some dear farmer friends in Jiangxi Province whose handicapped son had given up and thrown himself into a river. Two rather gruesome suicides impacting my life on the same day. How tragic it can be for families and friends of those who take their own lives.

Our love and kindness is needed for those around us in order to help prevent suicide, no matter how much we may disagree with their religious views, their politics, or their lifestyles. Those who are feeling alone, depressed, or rejected may be vulnerable to suicide. Kindness and love can save lives. Kindness and love is also desperately needed for the families and friends of those who commit suicide, for their trauma and anguish can be devastating.

In reading some of the studies related to suicide and some of the reports and arguments dealing with the role of religion and the Church, it has been interesting to see how complex the issues are and how easy it is for serious mistakes to be made when one just relies on gut feel, emotion, and simple assumptions in assigning blame. Too many critics go no deeper than just noting that Utah has a high suicide rate and concluding it must be because Utah has lots of "Mormons" (51%)--or rather, the people often nicknamed Mormons, but properly called members of The Church of Jesus Christ of Latter-day Saints.  Our critics often think they are making the world better by leading people away from or out of the Church, but in terms of suicide prevention, they may be making things much worse.

For faithful Latter-day Saints seeking to understand the issue of suicide and wishing to push back on unfair criticism, it is not enough to merely point out the fallacy when critics assume that Utah's suicide problem is due to the teachings and policies of the Church.  There are more intelligent arguments and evidence suggesting that LDS religious influence can contribute to a sense of shame or rejection among LGB youth that can plausibly increase their suicide risk. This is a danger we need to be aware of and work to mitigate with love and kindness. While religious involvement and especially attendance in religious services appears to be a strong positive factor in reducing suicide risk, there are offsetting factors that also need to be considered. It's a complicated issue. More work is needed to understand causes and effects.

Reports pointing to possibly negative impacts from the Church can be found in the following:
I wish to agree with these authors that the obvious problem in our midst demands action now to help reduce the problem. But some will assume that the action needed is not just our personal efforts to be kind, but systematic efforts to get people out of the Church or to reduce its influence or to dramatically change its policies and teachings. In light of the strong empirical data on the benefits of religious faith and religious activity in reducing suicide, such actions would seem to be misguided. A wise response requires understanding the many factors that can contribute to suicide before pointing fingers and prescribing unhealthy cures.

Not to be a pill, but it seems to me that none of these reports cited above, nor any of the various criticisms I've seen that seek to blame the Church for Utah's high suicide rate, has given any serious attention (usually not even a footnote or mention of any kind) to one of the most important factors associated with high suicide rates in the United States and around the world. Have you heard about this? It's altitude. That's right, distance above sea level. Huh? How can that affect suicide?

The Lowdown on High Altitudes and Suicide

A wide variety of recent studies show that one of the most persistent and significant factors associated with high suicide is altitude. The mechanism is still a subject of research, but the lower oxygen levels at high altitudes can have an effect on serotonin and while that can be positive for many people, it can exacerbate or contribute to depression for others. Multiple studies now point to altitude as having a significant effect on suicide. There is still more to understand and debate, but this is a noteworthy development.

See Rebekah S Huber et al. (including Perry Renshaw, mentioned below), "Altitude is a Risk Factor for Completed Suicide in Bipolar Disorder," Medical Hypotheses, 82/3 (March 2014): 377–381. Huber et al. examined data from 16 states for the years 2005–2008, representing a total of 35,725 completed suicides in 922 U.S. counties. They found that those with bipolar disorder (BD) who committed suicide preferentially did so at high altitudes, and that altitude had a stronger effect on sufferers of BD than it did on other mental illnesses.

The first such study I am aware of is C.A. Haws et al. (including Perry Renshaw), "The possible effect of altitude on regional variation in suicide rates," Medical Hypotheses, 73/4 (Oct. 2009): 587-90, with this abstract:
In the United States, suicide rates consistently vary among geographic regions; the western states have significantly higher suicide rates than the eastern states. The reason for this variation is unknown but may be due to regional elevation differences. States' suicide rates (1990-1994), when adjusted for potentially confounding demographic variables, are positively correlated with their peak and capital elevations. These findings indicate that decreased oxygen saturation at high altitude may exacerbate the bioenergetic dysfunction associated with affective illnesses. Should such a link exist, therapies traditionally used to treat the metabolic disturbances associated with altitude sickness may have a role in treating those at risk for suicide. 
So Haws et al., like other authors, note that high altitude doesn't make everyone more likely to commit suicide, but seems to be a strong factor for those already suffering from serious mental health issues.

Now a variety of additional studies have been published, with several cited in the Huber et al. article above.

One study of particular interest is that of Barry Brenner, David Cheng, Sunday Clark, and Carlos A. Camargo, Jr., "Positive Association between Altitude and Suicide in 2584 U.S. Counties," High Altitude Medicine & Biology, 12/1 (April 2011): 31–35; doi: 10.1089/ham.2010.1058. While earlier studies looked at mean elevation of various states, Brenner et al. recognized that altitude within a state can vary widely, so they looked at mean elevation for individual counties. They analyzed the data from over 2500 counties in the continental United States, giving much higher granularity than was possible in earlier work. "The higher-altitude counties had significantly higher suicide rates than the lower-altitude counties. Similar findings were observed for both firearm-related suicides (59% of suicides) and nonfirearm-related suicides. We conclude that altitude may be a novel risk factor for suicide in the contiguous United States." Below is an excerpt and a chart:
Despite a negative correlation (r = −0.31, p < 0.001) between county altitude and the all-cause mortality rate, there was a strong positive correlation (r = 0.50, p < 0.001) between altitude and suicide rate at the county level (Fig. 1). Positive correlations were also observed for both firearm-related suicides (r = 0.40, p < 0.001) and nonfirearm-related suicides (r = 0.31, p < 0.001). Controlling for five potential confounders (percent of age >50 yr, percent male, percent white, median household income, median family income, and population density of each county), increasing altitude deciles were associated with significantly higher suicide rates.... The threshold value for increased suicide rates occurred in the range of 2000–2999 ft.... Similar findings were observed for firearm-related suicides, which comprise 59% (352,052 firearm suicides per 596,704 total suicides) of all suicides.
Such findings are gradually making it into popular media, though I suspect that many of us haven't heard much about this yet. One very readable and interesting report is Theresa Fisher, "There's a Suicide Epidemic in Utah — And One Neuroscientist Thinks He Knows Why,", Nov. 18, 2014 (a hat tip to Russell Osmond for this article). For a Wyoming perspective, see Joe O'Sullivan, "Altitude may be major factor in suicide," Casper Star-Tribune, Sept. 18, 2011. An excerpt follows:
When it comes to suicide in Wyoming, guns often take the blame as a contributing factor. So does the isolation and flinty independence of rural culture. But a possible cause now being looked at appears to be a more important contributor to self-inflicted deaths: altitude.

Researchers at the University of Utah have found a correlation between how high above sea level people live and per capita suicide rates. Between 1999 and 2007, Wyoming had the fourth-highest rate of suicides per capita in the nation, according to the Centers for Disease Control and Prevention; states in the Mountain West hold nine of the top 10 spots.

The researchers looked at 35 separate factors that could cause suicide. Using suicide data from the CDC and mapping data by the National Aeronautics and Space Administration, they found a distinct correlation between elevation and suicide.

“The Rocky Mountain states just jumped out at you,” said Dr. Perry Renshaw, a professor at the university who took part in the research. “No matter what we did, the altitude kept coming up with a significant factor.”

The study shows that suicides occur between 60 and 70 percent more frequently at high elevations compared to sea level, according to Renshaw.

In fact, altitude surpassed both the isolation of rural culture and the prevalence of gun ownership, both of which come up as assumed causes for the high suicide rate, according to Renshaw. Altitude was the second-highest ranking of 35 variables. The only suicide indicator that ranked higher was being a single mother, he said.

Renshaw, who has spent 15 years studying brain chemistry, said lower oxygen levels in the brain affect people with depression and bipolar disorder.
Both of those disorders involve problems with how the brain uses energy, according to Renshaw. Recent research suggests that the amount of oxygen a person receives affects their mental faculties and performance.

“In depression, what we find is that there are changes in these high-energy compounds in the brain,” Renshaw said.

While oxygen makes up the same percentage of air at sea level as it does at high altitudes, atmospheric pressure — the amount of molecules compressed into one space — decreases with height.

That means people take in fewer oxygen molecules with each breath in a city like Casper, which is a mile above sea level, compared to someone living at sea level.
Comparisons outside the U.S.

To prove the data wasn’t just a fluke, Renshaw and the researchers looked overseas to prove their hypothesis. They did this by analyzing suicide rates in a mountainous country with an elevation that at its highest reaches 6,398 feet: South Korea.

“It was exactly the same result,” Renshaw said, referring to a comparison of suicides in South Korea with the Mountain West. “The higher you went, the higher the result.”
More recently, the Salt Lake Tribune has reported on the significance of altitude. See Luke Ramseth, "University of Utah research shows high altitude linked to depression and suicidal thoughts," Salt Lake Tribune, July 18, 2018.

Understanding the impact of altitude for those facing depression or other mental health challenges may now help guide medical professionals in better assisting patients, including single mothers (being a single mother turned up in one study as just about the only risk factor more significant than altitude). If nothing else, getting away to a lower altitude area for a while might be a big help.

A recent publication involving the Andes, not done by Renshaw, also points to a possible altitude effect, though the authors don't seem familiar enough with Renshaw's work to explain why an altitude effect might exist. See Esteban Ortiz-Prado, "The disease burden of suicide in Ecuador, a 15 years’ geodemographic cross-sectional study (2001–2015)," BMC Psychiatry, 17
(2017): 342; doi: 10.1186/s12888-017-1502-0. They found that "Provinces located at higher altitude reported higher rates than those located at sea level (9 per 100,000 vs 4.5 per 100.000)." A much higher suicide rate for the high-altitude provinces.

These studies are significant enough that they really must be considered by anyone seeking to understand the issue of high suicide rates in the Mountain West or elsewhere, IMHO.

Parkinson's Swift Dismissal of Altitude: A Reminder on Interactions

Altitude actually was mentioned in one of the articles cited above pointing to the Church as a possible factor in suicides. Daniel Parkinson in the first and most recent article listed above mocked the idea that altitude could be an important factor in the statistics pertaining to suicide rates in Utah (see "Utah’s Escalating Suicide Crisis and LDS LGBTQ Despair," Rational Faiths, March 14, 2017). Parkinson is rightfully alarmed at the increase in suicide rates among young people in Utah. But while he and his collaborators have considered many factors in their previously published analysis, they appear to have neglected what may be one of the most important factors, altitude. Altitude as a factor in suicide is a trend that shows up not just across the US but across the world. That doesn't mean that a high population will always have more suicide than a low population, for there are many factors playing a role and human behavior is complicated. But it shows up as a major predictive factor for suicide and should not be overlooked, in my opinion.

Parkinson's swift dismissal of this factor is motivated by the fact that suicide rates in Utah have recently shown an alarming increase, while the altitude obviously isn't changing:
Utah’s rank in overall suicide rate went up from #11 in 2014 to #6 in 2015. This is one area where we don’t want to be #1 but we are heading that way. Sorry folks, it’s not the altitude. As far as I can tell the altitude hasn’t changed lately. Altitude might explain our elevated baseline prior to these increases but it in no way explains a tripling of youth suicides nor these alarming trends among other age groups.
That may sound plausible at first blush, but I was frankly surprised and disappointed by the reasoning here, especially since I expected that Dr. Parkinson should be used to dealing with multivariate analysis and the very common possibility of interactions between the factors considered. Instead, he assumes that any effect of altitude will be a constant part of the baseline and cannot play a role in explaining a change over time.

Consider an analogy to skin cancer. It's an easier issue to consider, I feel, because it's less emotional than suicide and religion, and many people already know that higher altitudes have stronger UV light because the light passes through a shorter distance in the atmosphere resulting in less filtering by ozone. "UV intensity increases with altitude because there is less atmosphere to absorb the damaging rays," as the EPA puts it. "Colorado, for instance, has one of the highest melanoma rates in the country, likely due to its elevation," according to the Dana-Farber Cancer Institute.

Now let's consider two hypothetical regions with 100,000 people each, one region at sea level and one in the Rockies. Let's assume both places have similar populations each with two groups, a "safer" group of 90,000 people who prefer to stays indoors and wear sunblock and protective clothing when outdoors, and an "at risk" group of 10,000 people, initially, who love to engage in unprotected sports and sunbathing. The safer groups in both regions may have a low level of skin cancer (let's say 50 new cases per 100,000 people per year), while the at risk groups will have higher rates, with the at risk group in the high region having a significantly greater rate of cancer (let's say 300 new cases per year per 100,000 people at high altitude and 100 new cases per year per 100,000 people at low altitude). With these assumptions, the new cases of skin cancer per year for the whole population of 100,000 people will be 55 at low altitude (50*90,000/100,000 + 100*10,000/100,000) and 75 at high altitude (50*90,000/100,000 + 300*10,000/100,000). So there's the baseline difference of 20 cases per year.

Now assume that after 5 years at a steady rate, something happens that begins increasing the cancer rate in both locations. One scenario is that the number of people at risk increases. For skin cancer, this could mean more people abandon their indoors lifestyle and take up dangerous activities like golf and jogging. I'll neglect many details such as the years of delay that can occur between sun exposure and skin cancer and assume that the skin cancer increase shows up relatively quickly as sun exposure increases. 

Both locations will now have curves with an upward trend. Will the curves look the same, with the same rate of increase, differing only by a constant baseline? No. See the numbers shown in Table 1 and the curves displayed in Chart 1. As the at risk groups increase, the added numbers in the group at high altitude will experience a greater increase in skin cancer because they are being exposed to stronger UV. With the same population and behavioral dynamics going on, the high region will show a greater rate of increase in the skin cancer rate. It's not because of some pernicious unhealthy impact of Rocky Mountain Mormons, but because the altitude effect magnifies the rate of increase even when all else is the same. It's due to just about the simplest interaction imaginable, one of the many interactions between factors that are part and parcel in the social sciences, in health care, and in just about any other field where multiple factors may influence outcomes.

Table 1 New Skin Cancers
Year Safer Pop.  At RIsk Pop. Low Alt.  High Alt. 
1 90,000 10,000 55 75
2 90,000 10,000 55 75
3 90,000 10,000 55 75
4 90,000 10,000 55 75
5 90,000 10,000 55 75
6 82,000 18,000 59 95
7 74,000 26,000 63 115
8 66,000 34,000 67 135
9 58,000 42,000 71 155
10 50,000 50,000 75 175

In the period with increasing skin cancer, the slope (increase in cases per year) is 20 at high altitude, but only 4 at low altitude. One could lament that skin cancer has more than doubled in 5 years in the high altitude location, while showing a much lower increase elsewhere. What exactly are those lofty high-altitude Mormons doing to spread disaster in their communities? (Hint: it may not be the Church's fault!)

Here we have just about the simplest interaction possible in the data: a simple relationship between the cancer rate in one group and altitude. Interactions can be much more complicated and nonlinear, but even a simple and plausible one results in the kind of differences in rate between two regions that have caused such alarm and finger-pointing in suicide statistics. Altitude cannot be neglected, now that multiple studies have shown it is one of the most important factors in suicide. When other factors are increasing the overall suicide rate, altitude can exacerbate the problem, just as it exacerbates the skin cancer rate in the hypothetical scenario explored above.

But what if the size of the at risk population group does not increase in our analysis above, and instead the rate of skin cancer increases overall because the at risk group experiences a steady increase in cancer rate (say, 20% per year) due to environmental factors or some other reason? Perhaps an interaction with alcohol and drugs, decreasing antioxidants in diet or legislation that bans the most effective ingredients in sun block? We can still see similar results.

Here we keep the two population groups constant (90,000 in the safer group and 10,000 at risk), but in year 5 we begin increasing the skin cancer rate by 20% a year for both the low and high altitude at risk populations. The numbers are shown in Table 2 and the curves are in Chart 2. Here the average slope over the last 5 years ((rate at year 10 - rate at year 5)/5 years) is 8.93 for the high-altitude location and 2.98 at low altitude, or about 9 and 3, for a 300% difference in the rate of increase. It's those Mormons again, no doubt!


Table 2

Cancer Rates:

Year New Skin Cancers Safer Group At Risk, Low Alt. At Risk, High Alt.
1 55 75 50 100 300
2 55 75 50 100 300
3 55 75 50 100 300
4 55 75 50 100 300
5 55 75 50 100 300
6 57 81 50 120 360
7 59.4 88.2 50 144 432
8 62.3 96.8 50 172.8 518.4
9 65.7 107.2 50 207.4 622.1
10 69.9 119.6 50 248.8 746.5

My point here is not just to belabor the obvious error that Parkinson made in his hasty assumption that any impact of altitude on suicide statistics could only show up as a simple shift in baseline values and could not result in a difference in slopes. Rather, I'm calling into question multiple reports and accusations attempting to paint the Church as the key cause of high suicide rates or increasing suicide rates in Utah or in the Mountain West, without having controlled for or thoughtfully considered the possible impact of altitude.

If you look at the distribution of LDS members based on percentage of the population in each state, you see a high concentration in the most mountainous states, as shown in the chart below from Wikipedia's article, "The Church of Jesus Christ of Latter-day Saints membership statistics (United States)." So any analysis of suicide and the relative proportion of Latter-day Saints in a region could be confounded with the impact of altitude. Unless altitude is considered in the analysis, the results may be meaningless and misleading.

Unfortunately, Benjamin Knoll's work may be particularly jeopardized by this potential problem. In his report, "Youth Suicide Rates and Mormon Religious Context: An Additional Empirical Analysis," Rational Faiths, March 9, 2016, he lists states in order of their LDS percentage, shows bars for changes in youth suicide rate, and sees an "obvious" relationship suggesting that the presence of LDS people in a state is associated with suicide (click the chart below to enlarge).  But the high bars on the leftmost high-LDS end of the graph that support the curve Knoll has drawn are largely from high-altitude states, or, in the case of Alaska, have a complex factor of many Native American males with extremely high suicide rates that may require special consideration in the analysis.

I'm also puzzled as to how California ends up near the middle with an LDS influence somewhat less than Alabama or Arkansas, and just greater than Connecticut. The statistics shown by Wikipedia put California with a much higher relative LDS population. Something may be amiss. Further, the apparent 0 bar size for Wyoming is a surprise since Wyoming has seen suicide increase at a rate greater than the US national average. Is it apparently zero because the 2009 data wasn't found? Maine and several other states seem to be in the wrong place.

I need to go over Knoll's data and rerun his analysis, or maybe one of you would like to in your abundant spare time, because I am quite surprised by his claim to have adjusted R2 values of  0.65 and 0.69, respectively, for the relationship between % LDS population in states and the state youth suicide rate for 2009 and 2014, respectively. The data seem scattered all over the place and I just can't imagine such a high correlation is present. Here is Knoll's chart (click to enlarge) for these suicide rates (the above chart, recall, is for the rate of change in suicide rates, taking the difference between 2014 and 2009 data). High on both ends with scatter all over. This really gives a strong correlation in both years? But perhaps once controlled for other factors, it pops out. What happens when altitude is added? More work is needed, as always.

Regardless of the problems with specific states or other details in this analysis, the failure to consider altitude creates the risk of confusing the known effects of altitude for the more speculative effects of LDS religion in seeking to assess potential causes of the suicide problem in the US. Whether one looks at current suicide rates or rates of increase in suicide, altitude can play a role. It really needs to be considered and not dismissed with with a flippant quip.

When the analysis is done more carefully, there may still be good reasons to worry about LDS influence. Will those reasons outweigh the known strong positive effects of being active in religion and in the LDS Church in particular when it comes to promoting mental health and reducing the risk of suicide? In other words, will we be helping those at risk for suicide by leading them out of the Church and keeping them away from LDS neighbors? In the absence of meaningful data and valid analysis for such a conclusion, I think we need to be careful about pointing fingers and focus our energy on encouraging healthy and positive steps by all of us to better support and love those around us, recognizing that many may be in need of more support to overcome the pains and burdens they face. On that point, I heartily agree with Daniel Parkinson, Michael Barker, Benjamin Knoll, Dan Reynolds, John Dehlin, and, of course, The Church of Jesus Christ of Latter-day Saints.
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