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Living at an elevated risk

A growing body of research from the University of Utah has found a strong correlation between elevation and the suicide rate

CANMORE – For many people who call the mountains home it’s hard to imagine a better place to live, however emerging research out of the United States suggests there may be more to our mountain environment than meets the eye.

A growing body of research from the University of Utah has found a strong correlation between elevation and higher rates of suicide, a risk factor local health authorities in the Bow Valley have never considered.

While more research needs to be done locally, research south of the border has long shown the highest rates of suicide in the United States occur in states that span the Rocky Mountains – also referred to as the suicide belt.

Perry Renshaw, a professor of psychiatry at the University of Utah, has been studying the phenomenon since 2008 when he first moved from Boston to Salt Lake City.

“When I moved here, I was really struck by looking at a map of how divergent rates of suicide were across the United States,” said Renshaw. “You’ve got the suicide belt, which looks a whole lot like the Rocky Mountains.”

At the time, he said the two most prominent theories of the day linked the high rate of suicide to the high rate of gun ownership, as well as the region’s low population density.

While those theories were largely accepted at face value, Renshaw saw things differently thanks to his research in Boston, where he studied how people’s brain chemistry changed when they had a mood disorder. 

Curious if the high suicide rate had to do with the brain’s chemistry, he decided to look at how altitude and the lack of oxygen affects the brain’s ability to create serotonin, the neurotransmitter that moderates mood and anxiety, and dopamine, the neuro­transmitter associated with risk­-taking behaviour and adrenalin.

“It was a really simple hypothesis,” said Renshaw. “If you’re at a higher altitude, you’re going to have more problems utilizing energy in the brain than if you are at a lower altitude.”  

In order to test his hypothesis, he decided to look at 20 risk factors that have been known to trigger suicide and after comparing everything from education to per capita income, altitude was the second most significant indicator of suicide risk.

To better understand why, he began looking at oxygen levels at higher elevations and found rates of suicide begin to increase at 2,000 feet above sea level – the same level where there is a notable decrease in oxygen levels.

He said his research showed when there is less oxygen, the brain isn’t able to create as much serotonin, leading to greater levels of depression and anxiety.

To strengthen his findings, he took it a step further by testing his theory using rats.

In the test, researchers kept rats at different altitudes for a week before putting them through a forced swim test, a scientific way to measure for depression. When dropped into tanks of water, the rats that were kept at higher altitudes stopped swimming much sooner than those that had been at sea level, an indicator of depression-like behaviour.

The results helped prove that high altitude exposure reduces the production of serotonin and as a result increases the risk of depression and anxiety, which have been strongly associated with suicide in the developed world.

Adding more weight to his findings, his research team also discovered that common antidepressants such as Paxil, Lexapro and Prozac aren’t as effective at high altitude.

“It all came together in a relatively simple way in terms of the chemistry,” said Renshaw.

While lower levels of oxygen inhibit people’s ability to produce serotonin, his research team also discovered lower levels of oxygen might also be a reason people enjoy living in the mountains.

He described the finding as the “Utah-paradox.”

“Dopamine is conventionally thought of as being the neurotransmitter that really allows you to like whatever it is that you happen to like, whether it is riding your bicycle up mountains, or drinking hot chocolate instead of beer,” said Renshaw.

“When you go up in altitude, and the threshold for this effect is not as well known as for serotonin, you start making more dopamine and whenever you make more dopamine you’re going to enjoy whatever it is that you’re doing.”

He said this might be a reason why so many people are drawn to the mountains, or choose to take bigger risks at higher elevations, like skiing in the backcountry.

“There’s something about mountains and we believe it’s the low oxygen and the increased production of dopamine that creates a large number of people who love living in the mountains.”

Despite the growing amount of research proving the link between elevation and the suicide rate, Renshaw’s research was initially met with resistance from the scientific community, healthcare providers and governments.

“It was really hard getting our first research paper published because people thought we must be crazy, or they didn’t believe us,” said Renshaw.

“Some people feel that when we talk about altitude that we’re saying that only altitude matters and that’s not the case. Our findings add to the literature of a number of risk factors like gun ownership, living in a remote area, or bad economic times.”

While he acknowledged there are plenty of other risk factors that should be considered, he said the suicide rate in mountainous regions could be cut by 25 per cent if the impact of altitude was taken seriously.

“Suicide in a specific instant is a very complex, very personal tragedy and the idea that something as simple as measuring altitude is going to give you all the answers isn’t true, but it is true that in principle we could reduce suicide rates by about 25 per cent if we could take care of and more adequately identify and treat altitude-related mood disorders.”

Since his first research paper was published in 2009, he said it has been replicated in more than 10 different countries across the world from Peru to South Korea and the same correlation between altitude and suicide rates has proven true despite the vast differences in mountain culture.

Locally, the correlation between elevation and the suicide rate is less clear largely because it has never been considered a possible factor.

In Canmore, the average suicide rate has been above the provincial average four out of the past five years, with three recorded suicides in 2017 accounting for a suicide rate of 21.4 deaths per 100,000 people, according to statistics provided by the Centre for Suicide Prevention in Calgary.

Provincially, the suicide rate has been gradually increasing from a low of 12.3 deaths per 100,000 people in 2014 to 13.8 deaths per 100,000 people in 2018.

Last year Canmore recorded one suicide for a rate of 7.1 deaths per 100,000 people – its lowest level in the past five years.

Down the road in Banff the fluctuation in the suicide rate is even greater, ranging from 32 deaths per 100,000 people in 2014 to 10.7 deaths per 100,000 people in 2015 and 2016.

Last year the town recorded two suicides accounting for a rate of 22.5 deaths per 100,000 people.

While the rates of suicide fluctuate from year-to-year because of the towns’ small population sizes and the low number of people who die by suicide, both towns are located above 4,000 feet – well above the 2,000-foot threshold identified in Renshaw’s research.

“As you go above 2,000 feet, you should see an increase in the rate of suicide and it should become bigger and bigger as you go up further and further, with the caveat that you’re dealing with small numbers in a phenomenon that fortunately is relatively rare,” said Renshaw.

That appears to be true when comparing Canmore’s rate of suicide with Calgary’s, which sits at an average elevation of 3,445 feet.

According to the Centre for Suicide Prevention, Canmore’s suicide rate has been higher than Calgary’s in four of the past five years with 2018 being the only exception.

In Banff, which is slightly higher in elevation than Canmore, the rate of suicide has been both well above and well below the average suicide rate compared to both Canmore and Calgary.

Robert Olson, a librarian with the Centre for Suicide Prevention, said he had heard of the study before that found a positive correlation between the suicide rate and elevation, however, he cautioned not to put too much emphasis on that correlation.

“I’m not discounting it, but I think it needs to be researched more thoroughly,” said Olson, adding there are many other risk factors that can lead to suicide.  

He said the rate of suicide in Canmore and Banff can be greatly influenced by a single suicide from year-to-year making it difficult to draw any firm conclusions or trends.

“The difference of one suicide, either plus or minus, affects the suicide rate in terms of six or seven per cent, so it’s hard to gauge with a population that small and the suicide rate in relation to it,” said Olson.

Peter Quinn, executive director for Bow Valley Victim Services, said correlation doesn’t necessarily mean causation, particularly because in his experience a lot of people who die by suicide come from outside of the community.

“Over the years, there has been a high number of people that come to the area that die by suicide as part of their suicide plan,” said Quinn. “They deliberately travel hours and hours from other communities and come to this area and have very specific, detailed plans.”

Spencer Schneider, local manager for addictions and mental health with Alberta Health Services (AHS), said the provincial health agency has never considered how elevation might affect people’s mental health.

“It hasn’t really been looked at in terms of causal, or correlated factors,” said Schneider.

He said part of the challenge is that it is difficult to determine the statistical validity of the local suicide rate when a single suicide can cause it to fluctuate from one year to the next.

“That said, I don’t want to rule it out as something to think about.”

He said whenever there is a suicide in the Bow Valley and the person was working with his clinic within the last 60 days, a quality assurance review is completed to ensure the person received the best possible care.

He said the most prominent risk factors AHS considers when working with someone includes childhood neglect, substance abuse and/or a history of mental illness.

He said those factors can be compounded by secondary factors, such as precarious housing conditions like overcrowding living arrangements, or insecure accommodation.

Other factors include social isolation, family discord and financial stress.

“Anyone of those in isolation can be managed, but if you have two, three or four of those risk factors in place, that increases your overall mental health challenges,” said Schneider.

On the flip side, he said those risk factors can be counterbalanced by a core set of protective factors such as a connection to community, exercise, healthy sleep, positive family relationships, education and steady employment. 

“As soon as you get three or four or five protective factors in place, the number of risk factors almost becomes irrelevant,” said Schneider.

He said the Bow Valley is also fortunate to have access to a lot of health services, including two hospitals and lots of physicians.

“I think we have really good health services relative to our population, but I’d actually go beyond our health services and look at our community health services,” said Schneider, pointing to organizations such as Bow Valley Parent Link, Family and Community Support Services and the Community Helpers Program.

“We have some really good community services to kind of mitigate those risk factors.”

For Quinn, the best thing people can do who may be thinking about suicide is to talk to someone.

“The official statistics would say about four or five per cent of the population at any given time are having suicidal thoughts, so it’s a very common occurrence, but it’s a common occurrence that people don’t talk about,” said Quinn.

“If you keep stuff inside and you don’t talk to other people, those thoughts grow and they gain strength, but if you say it out loud and you start talking to other people about it you often start to see there are other options that are available.”

If you are in need of urgent mental health care visit the Canmore General Hospital or the Banff Mineral Springs Hospital from 2 p.m. to 9 p.m. seven days a week. No appointment or health care card is required.

If you need help outside those hours you can call the local distress centre 24 hours a day, seven days a week at 403-678-4696 extension 1.

For more information about mental health services that are available in the Bow Valley call Access Mental Health at 403-943-1500.