In the frontier state of Montana, where kids are taught from a young age to “cowboy up,” suicide has a stranglehold on its people. Residents, many of whom live in isolation, are killing themselves at a rate faster than almost any other place in the nation. Mental health professionals and government officials are scrambling to find a way to halt what has been deemed a crisis.
For nearly four decades, Montana has ranked in the top five states for having the highest rate of suicide, often placing at No. 1. In Big Sky Country, residents young and old alike kill themselves at nearly twice the national average.
Between 2005 and 2014, the crude rate of suicide in Montana was 22.33 per 100,000 people; the national rate during that period was 12.22 per 100,000. In raw numbers, 2,199 Montana residents died by suicide for an average of 220 people per year during this time period.
The Montana Suicide Mortality Review Team was created in 2013 by House Bill 583 and signed into law by Gov. Steve Bullock after mental health officials characterized the suicide rate as a “public health crisis.” The team started examining death certificates and talking to coroners, looking for answers behind the troubling phenomenon.
After examining the 555 suicides that occurred in Montana between Jan. 1, 2014 and March 1, 2016, the team concluded that access to lethal means (firearms), alcohol, a sense of being a burden, social isolation, altitude, undiagnosed and untreated mental illness, lack of resiliency and coping skills, and a societal stigma against depression all contribute to the long-term, cultural issue of suicide in Montana.
The report further stunned an already shocked state:
- In Montana, between 2005 and 2014, suicide was the number two cause of death for children ages 10-14, adolescents ages 15-24, and adults ages 25-44, behind only unintentional injuries (CDC, 2016)
- In 2015, 29.3 percent of high school students in Montana reported they felt so sad or hopeless almost every day for two weeks or more that they stopped doing some of their usual activities (Montana Youth Risk Behavior Survey, 2015).
- For 2014 and 2015, the highest rate of suicide in Montana is among American Indians (35.5 per 100,000) followed by Caucasians (28.1 per 100,000).
“What is a realistic investment in saving lives?” asked Matt Kuntz, executive director of NAMI Montana. “We have been trying to solve the problem for decades in the dark.”
With the help of a $303,000 grant from the Montana Research and Economic Development Initiative, comprised of committed facilitators and the Montana State University Center for Mental Health Research and Recovery, a new youth suicide prevention intervention program has been introduced to about 1,400 seventh- and ninth-grade students in eight Montana schools.
“Montana may have just taken the lead in bringing the best suicide prevention program in the world to the state,” said Kuntz, who once was on the brink of hanging himself.
No one knows if this is the solution and no one has the answers, Kuntz added. But, he said, you have the “burden” to bring the best existing evidence available to the state, and he believes this might be it.
“How to do this right is something we’re learning as we go,” Kuntz said in a telephone interview with Rural Health Quarterly. “The critical thing is to be guided by the evidence but with the realization that at the same time kids are dying without effective suicide prevention training.”
THE YAM PROGRAM
The research-based program, which has been found to reduce suicide attempts and suicidal thoughts by more than 50 percent, is called YAM, or Youth Aware of Mental Health. The five-hour program is spread over five weeks. Using trained facilitators, YAM includes interactive talks, as well as three hours of role-playing and mental health referral resources for youth. The program is designed to teach both mental health awareness and risk factors that are associated with suicide, as well as a set of skills for dealing with adverse life events, according to Matt Byerly, M.D., director of the MSU Center for Mental Health Research and Recovery.
It is one aspect of a multifaceted approach to reducing deaths by suicide in Montana and has the endorsement of the Montana Suicide Mortality Review Team. There is a myriad of prevention programs all aimed at reducing suicide, but Byerly said this is the right one for Montana.
“It has the best evidence for reducing suicide attempts and suicidal thoughts in adolescents,” he said.
An important component of YAM is that it is directly delivered to each youth, rather than to “gatekeepers,” or those people who frequently interact with youth, such as teachers, school staff and community leaders, Byerly said.
Montana and Texas are the first states in the nation where YAM is delivered.
In addition to delivering the program to students, researchers will conduct an initial study to determine YAM’s feasibility and acceptability by youth, their parents, schools and communities in the U.S., Byerly said. A third component of the effort is to adapt YAM so that it is culturally appropriate for high school students, American Indian students and youth of military service families in Montana.
“Not only do we want to pilot YAM to determine its effectiveness, but we want to see if it is a good fit for Montana,” said Karl Rosston, suicide prevention coordinator for the Montana Department of Health and Human Services. “There’s not many programs that have been tested first in Montana. This gives us an opportunity to see it from the start.”
The pilot study was completed in the spring. Follow-up assessments were completed in early June and data entry is under way, Byerly said. There are currently no results. However, Byerly said, “Informal feedback has suggested that the intervention is well accepted by students and schools.”
Montana’s staggering suicide rate has long been under the watchful eye of Democratic Gov. Steve Bullock. He has argued that the state has a responsibility to do all it can to protect individuals from suicide and ensure that every young person “knows their value” at school, home and in their communities.
“The YAM program takes on this responsibility head-on and is especially important to not only reducing the risk of suicide, but helping young people develop the underlying emotional health resilience they need to navigate stressful situations in life,” Bullock said.
YAM was developed in Sweden, and more than 11,000 ninth grade students in 10 European countries participated in the initial study. Results of the study showed that YAM was the only intervention of three that was superior to the control group, reducing suicide attempts and suicidal thoughts by more than 50 percent compared to the control group. The findings were published in the journal “Lancet” in 2015.
One of the authors of those finding was David Brent, M.D., a psychiatrist in Pittsburgh, Pa. affiliated with UPMC-University of Pittsburgh Medical Center.
“No one program could address all the issues,” Brent told Rural Health Quarterly. “YAM is a good choice because it is one of the few programs that has been rigorously evaluated and cuts the rate of suicidal ideation and attempts in half. It cannot be the whole solution, but I believe the folks in Montana have been strategic and that this is one of several initiatives.”
Four master trainers of YAM visited Bozeman in April to provide a week-long training for YAM facilitators, which was the first training of its kind in the U.S. Twelve Montanans and three Texans completed the training.
Carl C. Bell, M.D., is a staff psychiatrist at Jackson Park Hospital Family Medicine Clinic in Chicago and is a member of the Rosalyn Carter Mental Health Task Force. He described the YAM program as a “good start.” Bell said he has seen various research projects on suicide prevention move forward, but they are all poorly designed and usually focus on preventing suicide behavior. But, he maintains, that does not mean such interventions are actually preventing suicide.
Bell told Rural Health Quarterly that after familiarizing himself with YAM he is “not impressed.”
Kuntz and Byerly disagree.
“How long would it take something else coming down the pipeline to demonstrate this level of effectiveness,” Kuntz asked. “Is there anything else on the horizon that looks like it could be nearly this effective in reducing depression and suicidal ideation through a population intervention in high school youth? A key component of YAM is that the program is delivered by a group of people with expertise working with youth regarding mental health issues,” Byerly said. He emphasized that many of the facilitators are people who have advanced education in mental health fields, as well as teachers and community health professionals.
“Suicide is a huge problem in Montana—one of the biggest problems Montana faces,” Byerly said. “We’re fortunate to have this opportunity to be the earliest involved with a very promising intervention. Ultimately, we’ll be participating in evaluating the true impact of the intervention.”