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The Stigma of Suicide 

Tucson has the third-highest suicide rate in the country. Why is almost nobody talking about this fact?

Judy Schwartz recalls her husband's last visit to the cardiologist.

He was receiving care for a heart condition. He'd previously endured coronary artery bypass surgery, and the new therapy consisted of applying pressure to his heart to expand the blood vessels.

"The day that we went there for the first time, it almost looked like he was getting shock treatment," she says. "And he said, 'I can't do this,' and I said, 'Well, why don't you try it for a couple days?'

"That night, he shot himself."

Schwartz is telling her husband's story on a recent May afternoon. It's been exactly two years, three months and 28 days since her husband committed suicide.

"It's very surreal," she says. "It's really hard; two years later, it still seems like it happened yesterday, and (yet) that it happened forever ago."

The two left the gray skies of Columbus, Ohio, after 23 years and retired here in 2003. Her husband's suicide came out of nowhere, since she always thought of him as a strong-willed individual who persevered.

Right before he shot himself, he called a neighbor and one of their sons.

"I think he just snapped. I think something just happened that night. But in retrospect, my husband had always said when he was sick before, that if anything would ever happen, he'd, you know, just take care of it."

Schwartz, who now lives in Marana, was surprised to learn that Tucson has the third-highest suicide rate out of the 54 largest urban areas in the United States. A report, published last year, divulges a sad figure: 25 out of every 100,000 Tucsonans killed themselves in 2004. Only Las Vegas and Colorado Springs, Colo., ranked higher. (Mesa ranked sixth; Phoenix was No. 14.)

Published by the National Association of County and City Health Officials, the report, "Big Cities Health Inventory," used data from 2004. Local mental-health professionals say that three to four years of lag time is typical when it comes to these types of reports, but they also say the suicide rate in town is improving.

"We're not in the place we were in 2004," says Michael Barr, the training manager at the Southern Arizona Mental Health Corporation, who has 27 years of experience in the Pima County mental-health system. SAMHC is a nonprofit behavioral health center providing crisis care and services. Dealing with suicide is what the center does, offering open doors 24 hours a day, seven days a week, and a phone line, too. SAMHC helps people in crisis, regardless of their economic level or immigration status. The center takes in 8,000 walk-ins and receives around 80,000 phone calls annually. A new mobile service enables staffers to attend to people in their homes if they can't make it to the center.

"If somebody walks in here, and they've got issues, we're going to deal with it," Barr says.

Numbers from the Arizona Department of Health Services, published in March of this year, exemplify the uphill fight Arizonans are facing in their efforts to prevent suicide. For the third consecutive year, suicide among Arizonans 65 and older increased. Elderly white men continue to be the most vulnerable population. Native Americans age 15 to 19 committed suicide at a rate 2.8 times higher than all Arizona adolescents. Lesbian, gay, bisexual and transgender youth on average are one-third more likely to attempt suicide. Arizona's suicide rate of 15.9 people per 100,000 is above the national average of 11 per 100,000, with all states in the West higher than the national average, except for California. Every 17 minutes in the United States, somebody kills themselves.

Barr points outs recent improvements in certain sectors of the population, especially Native Americans and adolescents age 15 to 19. However, suicide is still the third-leading cause of death for people age 15 to 24. "That's pretty much across the country; it's not unique to Tucson or Pima County," he says.

But there's no denying that suicide is an issue in Tucson, one that carries a stigma and an unsettling veil of misunderstanding.

"We kind of push suicide under the rug," Schwartz says. "It's not pretty, and it's a very complicated grief, and it leaves lots of unanswered questions."

Schwartz participates in Survivors of Suicide (www.sostucson.org), a group comprised of people who have lost someone to suicide. Members meet twice a month and share their experiences, offering them a chance to relate to others who are dealing with the same types of feelings.

Tyler Woods is the group's facilitator. She first became involved 12 years ago as an intern and is now a certified holistic mental-health practitioner operating out of her modest house just off of Barraza-Aviation Parkway.

She's lost nine people over the course of her life to suicide, including a boss, a grandfather and a close friend who committed suicide while on the phone with Woods, unbeknownst to her.

"I'm a survivor, too, and you just learn to live with it," she admits. "You don't get over it."

For Woods, the No. 1 reason suicide is not often discussed is the stigma that surrounds it.

"It's a don't-talk, don't-tell; there's a taboo around that," she says. "We need to change the way we look at suicide. When someone dies of a cancer, and their immune system breaks down, we bury them.

"When someone's emotional immune system breaks down, we look the other way."

No one clear answer explains Tucson's high suicide rate. Mental-health professionals candidly offer opinions and possible reasons: a large retiree and older-adult population; the state's paltry mental-health system; drug abuse; sizeable military veteran and Native American populations; the transient nature of Tucson; and the availability of firearms.

But one problem is cited more than others: a lack of education and awareness. People don't know how to recognize suicidal tendencies in each other, or how to effectively talk about suicide and prevent it.

Barr, of SAMHC, is spreading the word by leading workshops to address suicide. Over the last two years, he's started teaching two suicide-prevention programs, SafeTALK and ASIST (Applied Suicide Intervention Skills Training), which were developed by LivingWorks, a Canadian intervention organization. A half-day program, SafeTALK helps participants identify people who have thoughts of suicide and connect them to the appropriate resources. ASIST is a two-day workshop covering intervention techniques.

The training is best for people--such as caregivers, Meals on Wheels drivers, teachers and guidance counselors--who interact with certain populations prone to suicide. In the last two years, Barr says, close to 1,000 people in Pima County have been trained.

Both SafeTALK and ASIST instruct people on how to spot "invitations": indications from people who are contemplating suicide, such as an off-hand comment about killing oneself or a co-worker disclosing to a colleague that they've found a "solution" to their depression.

"We need to be helpfully nosy, not intrusive. But when you suspect that suicide might be an issue, (you have) to ask the question in a way that's not judgmental, but sincere," he says. "There are three reasons we don't address suicide: We either miss it, or we dismiss it, or we avoid it."

On the anniversary of the Virginia Tech shooting, Barr is at the Doubletree Hotel conducting a SafeTALK seminar in a banquet room overlooking the hotel's courtyard. With a slideshow presentation behind him, and cheesy paintings of saguaros on each side, he is speaking to roughly 22 people from Nueva Luz, a local drop-in center, managed by HOPE, Inc., for adults with behavioral challenges.

Barr begins the workshop by disclosing stats that elicit surprise and more than a few "whoa" moments from the crowd, including Tucson's No. 3 ranking. Using slides and video clips, he explains why being inquisitive is vital.

"Most (people) want help in staying alive; that's an underlying premise here," he says. "Most people thinking of suicide don't want to die."

Suicide is not a hot-button campaign issue. Politicians don't give wonkish policy speeches on the reasons for suicide, or lay out grandiose plans or funding approaches to fight the problem.

Councilwoman Karin Uhlich says Tucson's suicide ranking is "shocking," though to her knowledge, the issue has never been brought up in a City Council meeting. Renee Sowards, an assistant to Councilwoman Shirley Scott, concurs that suicide has not been a council item. Both sympathized with people dealing with suicide, but admitted the council is not actively working on the issue.

"I don't think our government officials skirt the issue; it's just there are so many issues out there," says Survivors of Suicide's Woods. "When I do bring it up, or when anybody brings it up to city officials, we get a card saying someone will talk to us, and nobody does. Again, it's that stigma and taboo around suicide."

The media tend to report on suicide only in sensational situations, and a lot of mental-health professionals partly blame the media for the current stigma.

Schwartz and her husband never discussed suicide; this lack of dialogue is fairly common, says Donna Carender, a private consultant in gerontology who conducts SafeTALK and ASIST.

"I do this with older adults, because they're the ones who won't talk about suicide," she says. "People think depression's normal when you're old, and it's not."

Isolation, dealing with chronic pain and/or the death of a significant other can all plunge elderly people into depression. That's why Carender is reaching out to anyone she can think of who deals with older people, from people working and living in retirement communities to the drivers for Meals on Wheels.

Carender, with a leather binder in front of her stuffed with suicide-prevention literature, reiterates the need for older adults to ask questions and bat down the stigma that persists. And the training seems to be helping: Since the first area ASIST program last November, four successful suicide interventions have occurred. And every time Carender holds a training session, she receives phone calls asking her to do more, she says.

Carender believes suicide must be discussed openly if real change is to transpire.

"We're losing over two people a day in Arizona (to suicide)," she says. "If two people a day in Arizona are getting West Nile, it's going to be in the news, but two people in Arizona taking their own life doesn't make the news."

Like the elderly, Native Americans suffer from higher than normal suicide rates. Three suicides have already occurred on the Tohono O'odham nation this year as of this writing, after seven in 2007.

But Dawn Nesja is sanguine. She's only two months into her new job as youth-suicide-prevention grant manager for the nation, and she's laying the groundwork for preventative measures across the reservation. Originally from the Chippewa Nation of North Dakota, she's been living in Arizona for three years now, after growing up in Wisconsin. This year is proving to be fruitful; she's received federal grant money and is staffed with three specialists.

Native Americans age 15 to 19 commit suicide 2.8 times more than everyone else their age; that's why Nesja's work is imperative. Programs aimed at youth are sprouting up in schools and community centers--anywhere younger people can be told they're appreciated. In Nesja's opinion, the community is finally asking for help and is ready to confront suicide, which has plagued not only the Tohono O'odham, but nations all over the United States, for far too long.

"They think it's time," she says. "They're ready; they want to heal."

Nesja explains why suicide strikes so many Native Americans year after year.

"It has to do basically with substance abuse, alcohol and drug addiction, physical and sexual abuse; there's just a lot of abuse, mostly dealing with the historical drama the people have gone through," she says. "We're now focused on building cultural supports and values."

The younger generation must be dissuaded from suicide, and Nesja is planning numerous projects, such as physical activities like hoop dancing, to keep young folks active and healthy.

The awareness campaign is just getting underway, but the fact that behavioral health services on the reservation are becoming stressed due to an increase in people asking for help is a wonderful sign.

The rebellious stage for Daniel Moreno started at age 17; at least that's what his mom thought. Growing up, Daniel had always been a well-behaved and ambitious kid, a runner with plans to go to Harvard.

Then he started refusing to go to school. His mom told him to get a job or get out; he started living in a friend's garage.

When he was 18, Susan Moreno learned her son wasn't just being rebellious.

"I had him involuntarily committed," says Susan Moreno. "That was the first time I heard the word schizophrenia. ... I had to go online and look it up; I didn't even know what it was."

Schizophrenia can interfere with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, to make decisions and to relate to others, according to the National Alliance on Mental Illness (NAMI). The illness affects more than 2 million American adults age 18 and older.

Susan is president of the board of directors for NAMI-Southern Arizona (www.namisa.org). NAMI-SA is a nonprofit offering advocacy, education and support to people affected by serious mental illnesses.

After Daniel's diagnosis, he and his family went through five strenuous years. He tried living on his own, but that didn't work. He went through a bulimia stage due to the drugs he was prescribed. After the engine blew up in his truck, he tried to commit suicide. Susan found him on the floor of his bedroom in time to save his life.

In June 1995, Daniel decided to participate in a schizophrenia study at the National Institute of Mental Health (NIMH) in Bethesda, Md. Daniel and Susan thought it was a wonderful situation: Daniel was contributing to research on schizophrenia while being in the care of some of the best doctors in the world.

Three days before he was supposed to come home for Christmas, Daniel went outside to smoke a cigarette on the seventh floor of the NIMH offices. He scaled a glass wall 6 feet up and jumped to his death.

Just that morning, he had gone shopping, buying some boxer shorts.

"He was just feeling fine, we thought. All I can say is that I don't think it was Daniel in his right mind; it was Daniel in his delusional mind," Susan says. "What I believe is that schizophrenia took my son."

The numbers weren't on Daniel's side.

"In the 18-to-44 age group for individuals with schizophrenia, the suicide rate is roughly eight times the normal population," says Clarke Romans, executive director of NAMI-SA, and Susan's colleague. "Suicide's a difficult thing to study, but I think one of the main reasons is that the symptoms of the illness are so dramatic that the individuals really have a hard time coping with the illness and making any progress in what you'd call normal living.

"I think they just become hopeless, many of them," he adds.

According to statistics crunched by NAMI-SA and the NIMH, about 100,000 people in the Tucson area suffer from the three major mental illnesses: schizophrenia, bipolar disorder and major depression.

Romans says 70,000 of these people are undiagnosed and untreated, raising the possibility of suicide. Another obstacle: Mental illnesses aren't always covered under insurance policies. Arizona is one of only eight states without mandatory mental-health-insurance parity, meaning, for instance, that someone needing care for schizophrenia is not always covered, but a smoker and drinker who needs care for heart disease is always covered. To Romans, this is nothing but gross discrimination.

"Why do we have this? It's mostly because of ignorance of mental illness, and I hate to say it cynically, but treating mental illness isn't very profitable, so insurance companies are against it," he says. "So when you have that landscape, it's not surprising that the suicide rate for people with mental illness is a lot higher."

A bill to fix this inequality passed the State Senate Health Committee on a 5-1 vote in April, but it was referred to the Appropriations Committee, where no meetings are scheduled, and hopes are dim. The U.S. House and Senate have passed similar federal bills, but the two bodies have not reconciled their differences, leaving things hanging in Washington, D.C., too.

The legislative delay aside, Michael Barr of SAMHC remains optimistic that Tucson is improving its suicide problem--but the city still has a long way to go. The preventative efforts need to continue, and awareness must be raised to put suicide on the city's radar. All parties need to work together; more organizations and employers are going to need to be trained in programs like SafeTALK and ASIST.

"Some people can't deal with their problems, so they begin to conceptualize thoughts of suicide, so they're in this river of suicide," Barr says. "If nothing is done, then they can go over the dam and try to commit suicide. We're trying to stop it upstream."

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