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Friday, June 01, 2018

The High Suicide Rate in the Mountain States: Possible Effect of Altitude

The relatively higher suicide rates in Utah and other Mountain States has often been blamed on Mormonism or the culture of the Mountain West or the ready availability of guns, but one factor that some scientists and medical professionals are beginning to recognize is altitude itself.

Here is an abstract from a scientific publication, 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:
Bipolar disorder (BD) is a severe brain disease that is associated with a significant risk for suicide. Recent studies indicate that altitude of residence significantly affects overall rate of completed suicide, and is associated with a higher incidence of depressive symptoms. Bipolar disorder has shown to be linked to mitochondrial dysfunction that may increase the severity of episodes. The present study used existing data sets to explore the hypothesis that altitude has a greater effect of suicide in BD, compared with other mental illnesses. The study utilized data extracted from the National Violent Death Reporting System (NVDRS), a surveillance system designed by the Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control (NCIPC). Data were available for 16 states for the years 2005–2008, representing a total of 35,725 completed suicides in 922 U.S. counties. Random coefficient and logistic regression models in the SAS PROC MIXED procedure were used to estimate the effect of altitude on decedent’s mental health diagnosis. Altitude was a significant, independent predictor of the altitude at which suicides occurred (F = 8.28, p=0.004 and Wald chi-square=21.67, p < 0.0001). Least squares means of altitude, independent of other variables, indicated that individuals with BD committed suicide at the greatest mean altitude. Moreover, the mean altitude at which suicides occurred in BD was significantly higher than in decedents whose mental health diagnosis was major depressive disorder (MDD), schizophrenia, or anxiety disorder. Identifying diagnosis-specific risk factors such as altitude may aid suicide prevention efforts, and provide important information for improving the clinical management of BD.
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. 
Now a variety of additional studies have been published, with several cited in the Huber et al. article above. The lower concentration of oxygen 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.

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," Mic.com, Nov. 18, 2014 (a hat tip to Russell Osmond for this article and motivation for my post). 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.”
O ye mountains high, indeed!

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. We'd love to see you here in Shanghai, a place where you may find it's a good thing to have friends in low places.

Update, June 3, 2018: Some readers questioned why Colorado or the Andes weren't considered. Renshaw's work has considered the entire Mountain West and also many nations, and has seen the altitude effect repeatedly.

A very 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. 


Anonymous said...

No mention of Denver or Colorado in general? What about places like Quito, Ecuador or Nepal where people live at significant altitude. Studies seem a bit hokey to me; like they are cherry picking data to try to prove their hypothesis.

Anonymous said...

Anon 9:14, who knows --- but I wouldn't be very hopeful of getting comparable results by studying populations that have lived continuously at high elevations for thousands of years (and thus had time to adapt physiologically) and where cultures are significantly different. Lots of methodological problems to work through, I would think.

-- OK

Anonymous said...

I think the really astounding thing is how Utah's altitude has climbed between 2010 and 2015!


Anonymous said...

Quito and other South American cities/countries at high elevation have significant populations of European descendents, just like the US.

Richard said...

Did the study look at suicide/altitude occurrence in the appalacian mounntains om the U.S? That might be a better comparison than other countries (more closely aligned culturally, ethnically & etc.)

Jeff Lindsay said...

Renshaw's work has considered numerous places besides the US and has consistently seen the altitude correlation. That's mentioned in some of the articles I linked to.

A very recent publication involving the Andes, not done by Renshaw, also points to the altitude effect. 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)." Double the suicide rate.

And yes, Colorado was included in the studies. You can also read a perspective from the medical college at the Univ. of Colorado in Denver in Research Leads to New Conclusions about Link Between Suicide and Altitude. Colorado like some other parts of the country has had a dramatic increase in suicides, at least as of the data of that report.

Anonymous said...

Again, that rising altitude problem asserts it's nasty head.

C T said...

Female rats, who presumably have no cultural pressures that would affect the appearance of depression in them, show increased depression-like behavior when kept at higher altitude. See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4376288/

Still not leaving my mountain home, though.

Anonymous said...

Thanks for the additional links Jeff. A few interesting snippets from the Ecuadorian study:

The results show that living at high altitude has a very low chance to predict the occurrence of suicide (R2 = 0.0232, p = 0.477), however the relative risk (RR) analysis showed a slightly high increment in the risk of committing suicide when living above 2500 m

In the last 15 years, people who did not finish primary or high school had the highest suicide rates among Ecuadorians. Urban communities have almost triple the suicide rates of rural communities. The overall suicide rate by race shows that mestizos or mixed race has the highest rate (9/100.000), followed by indigenous (7/100.000) and all the other ethnic groups (2/100.000).

Other countries including Saudi Arabia, Syria, Jordan, Nepal and Jamaica reported some of the lowest rates worldwide.

Suicide seems to be more prevalent in high altitude provinces when compared to provinces at lower altitudes, however, this relationship does not demonstrate causality and further research is needed.

Anonymous said...

I think the correlation with elevation is very interesting.

I wonder: has anyone done a study regarding a possible correlation between the fallout of nuclear detonations and mental illness? The whole region were talking about has been affected one way or the other by tests done in Nevada between 1950 and 1992.


Anonymous said...

Comment posted by anonymous at 1:32 PM, June 02, 2018:

"I think the really astounding thing is how Utah's altitude has climbed between 2010 and 2015!"

Anon was alluding to the apparent spike in teen suicides during those years. It's important, though, that we remember that understanding and tracking the causes of suicide is a very complex process and that there may be multiple causes involved in each case.

That said, it may be useful to note that between the years of 2010 and 2015 Utah was the fastest growing state in the country:


So one might infer that if the population increase was due, in part, to the growth of families in Utah plus an influx of families relocating to Utah there would be a higher percentage of increase among youths and children as opposed to adults--thereby increasing the overall number of suicides among youth.


Anonymous said...

Or better said: thereby increasing the number of suicides proportionately among the youth.

Jason Robertson said...

The suicide rate has been increasing nationwide it’s not only the mountain states.


Jason Robertson said...

Also here is the CDC stats. 25 states have seen suicide rates increase more than 30%. Many of these are outside the inter mountain west.


Raymond Swenson said...

Air pressure and oxygen pressure falls off at higher rates at increasing altitudes. The loss between 2500 and 5000 feet is much greater than the loss from sea level to 2500 feet. The mountain states have significant populations in urban centers around 5000 feet and above, locations where people who need supplemental oxygen need significant increases in support from oxygen concentrators.