Last October, Ellensburg lost two young men. First-responders approaching the house on North Ellington Street didn’t know exactly what they would find, they were just ready to do their job, which they did.

According to Kittitas Valley Fire and Rescue Deputy Chief Rich Elliot, some of the firefighters were the same age as the two who had died in the fatal accidental shooting and suicide. Some of the firefighters knew them personally.

Elliot said that first-responders learn how to cope with seeing horrific things. In the 30 years that he has been a firefighter, Elliot has learned how to face both physical dangers and the weight of seeing people, members of his community, get hurt or killed. This doesn’t make it any easier when he has to deliver the news to the families of those who have been lost.

“I think when you sort of understand how upset they must be, the pain they're in, and you see that sense of loss, and sometimes they're angry, sometimes they're sad, everything is happening at once,” Elliot said. “That's hard.”

It’s a weight, though, that is being faced more and more in recent years. Not all scenes are like the one first-responders found that night, but Kittitas County is currently in the middle of a public health struggle worse on the local level than the opioid crisis. The killer here is suicide, taking an average of one person every month for the past two years.

The past decade has seen a relatively steady suicide rate of between four and nine suicide deaths per year. However, 11 people took their own lives in 2017, and in 2018 that number rose to 14, approaching rates twice the state average. Suicide is on the rise all over the country, but Kittitas County and similar counties are being hit the hardest.

In April 2018, the Kittitas County Public Health Department released its “Health of Kittitas County” profile, which details problems, risks, and the overall quality of life here in the community. When asked what their primary concerns were, the highest given answer by community members was mental health.

In recognition of suicide awareness month, which ran through September, it’s time to address these concerns and examine why Kittitas County is being affected worse than other places and what local experts are doing to address this.

HOW SUICIDE IS VIEWED

Too often, suicide is seen as a tragic yet unpreventable event with those who take their own lives being portrayed as simply unable to cope with life’s hardships. This explanation though, isn’t the perspective most health officials are taking in the modern day. This September, the World Health Organization (WHO) stated the following:

“Suicide is a serious public health problem; however, suicides are preventable with timely, evidence-based and often low-cost interventions. For national responses to be effective, a comprehensive multisectoral suicide prevention strategy is needed.”

Suicide doesn’t just happen out of nowhere. It can be prevented on a systematic level, as well as a personal one. If people reach the point where they see suicide as the only way out of their pain and suffering, something has gone wrong.

When looking at health systems, the Center for Disease Control and Prevention (CDC) often splits places into two categories: rural and urban. Kittitas County is mostly rural, and according to the CDC: “During 2001-2015, suicide rates were consistently higher in rural areas than in metropolitan areas.”

This can be seen in the rate of suicide which has increased over the past decades. Suicide rates have increased all over the country. King County, for instance, has seen an increase of 15.1% since 1999. In Kittitas County though, suicides have increased by 23.1%. If the situation is getting worse, why are rural areas hit harder than urban ones?

Sigrid Reinert is the Washington State Department of Health’s Suicide Prevention Specialist. She said that while rural counties can differ wildly in many ways, there are commonalities that may be some of the largest contributors to the disparity between rural and urban suicide rates.

“In rural counties it’s harder to get mental health help,” Reinert said. “They also have more agriculture which often have higher suicide rates. Agriculture is one of the highest-stress and hazard jobs. It’s often isolated and comes with a mindset of independence.”

There are three major factors to address which are consistent with CDC findings. The first is infrastructure which rural areas are often lacking. Second are environmental factors, and third is the culture in which people live.

INFRASTRUCTURE AND ENVIRONMENT

Rural areas simply have fewer resources to work with than urban areas, which can cause health issues of all kinds to hit harder. This has contributed to crises like the opioid epidemic which has devastated small rural towns all over the country. In the same vein but an urban example is the crack epidemic which crippled poverty-stricken neighborhoods in the 1980s.

Kittitas County isn’t entirely a poor community, but it does have a higher population living below the poverty line than the state or national average and is ranked second worst in the state for income inequality, according to the county public health department’s 2018 report (though it should be noted that the high population of university students does affect this).

People living in poverty have less money to use for health care, let alone mental health treatment. This means that part of this burden can be disproportionately placed upon emergency services personnel who respond regardless of a person’s income. They can only respond though when someone is already in a crisis, where their life is in danger, according to Deputy Chief Elliot.

“Yes, we have mental health issues in this community that result in crisis where police or EMS respond,” Elliot said. “That’s not the end of the world so to speak, but it’s one of the most damaging and expensive ways to deal with mental health. We would rather people have access to mental and behavioral health services before they get into a crisis.”

There are mental health services in the area provided by organizations like Kittitas Valley Healthcare, Comprehensive Healthcare, the CWU Student Medical and Counseling Clinic (SMACC), as well as private therapists and counselors around the county. While these places are full of hard-working and highly-skilled people using state-of-the-art treatment methods, there are still obstacles in the way of getting that treatment for everyone who needs it.

The SMACC does an overall great job of providing care for the university population according to many county health officials, and this success is shown statistically. Relatively few of the suicide deaths in this county are college-age, especially when considering that college students make up about one-fourth of the population. However, the SMACC is paid for out of university fees and thus can only take care of university students.

As a non-profit, Comprehensive Healthcare is perhaps the most affordable mental healthcare provider for non-university students. They currently treat over 20,000 people a year across Central and Eastern Washington using a variety of modern evidence-based treatments and have earned several awards in doing so. However, even those getting care from some of the most affordable places may have to pay hundreds or thousands of dollars in co-pays or deductibles.

Healthcare in Washington state costs an average of $641.96 per person according to the Washington State Health Care Authority (HCA). For many families, it is hard to justify adding mental healthcare costs on top of that.

But even those for whom cost is no issue, rural areas like Kittitas County have an increased risk when it comes to mental health and suicide. This is where environment comes into play.

Those in the farthest reaches of the county may have to travel a considerable distance for care. This distance also is a cause for social isolation.

People living in rural areas are also more likely to own firearms, making suicide attempts more likely to be fatal. This is why men die to suicide nearly four times more than women, even though women attempt suicide three times as often, as Kittitas County Coroner Nick Henderson explained.

“The largest means (of suicide) is firearms. More men complete suicide than women because men will use a gun. Women will usually take pills and either they don't take enough and they wake up, or they take enough and somebody finds them in time.”

CULTURE

Culture is one of the biggest parts of the suicide and mental health issue because no matter how much money is spent on training counselors and hosting support programs and funding clinics, if people aren’t making use of those services, nothing will change.

According to the CDC, rural areas often have a “culture of stoicism.” This is attributed to ideas of individualism and ruggedness that can come with isolated living and difficult work outdoors. A 2006 study published in Social Psychiatry and Psychiatric Epidemiology found that these qualities often come with reluctance to ask for help when in distress.

This is paired with the fact that rural areas tend to have higher levels of stigma surrounding mental health, making it even less likely that people will seek help. “Stigma” is a word that comes up a lot when discussing mental health, mostly because the past few decades have seen a widespread cultural shift away from seeing suicide as a personal failure and towards seeing it as a health issue that can only be improved if it is discussed by ordinary community members.

In Kittitas County, those discussions are well underway. Comprehensive Healthcare is currently presenting Mental Health First Aid workshops for community members in both English and Spanish, in order to reduce the stigma of suicide and teach people how to approach those who may be in a mental health crisis. The classes are attended by a wide variety of people, from CWU police officers who often have to respond to mental health-related calls, to people who just want to better understand how to help their friends and loved ones.

Diego Mendoza, one of the course’s two trainers, has worked at Comprehensive Healthcare for over 18 years, and said that reducing stigma is one of the most important parts of the courses.

“If we reinforce that stigma, people, especially young people, can hide their symptoms and not seek help,” Mendoza said. “Part of mental health first aid is identifying our roles in the lives of young people so we can work with them to find the causes and signs of these issues. That’s most important for everyday community members, which is why we have this training.”

If everyday citizens are given the knowledge to help each other, it will go a long way towards making things better. Sigrid Reinert, Mental Health Specialist at the Washington State Department of Health said, “Seeking help doesn’t always need to be professional help. Talk to a friend, a pastor, reach out and talk to others. We need to make it easier for people to ask for help.”

YOUTH, SCHOOLS AND JAIL

In a disturbing and maybe startling statistic, the 2018 Health of Kittitas County report showed that the number of depressed and suicidal 10th graders is on the rise, with an over 10 percent increase in teens who had considered suicide over a 10-year span.

It shouldn’t be shocking that children and teens experience depression and suicidal thoughts as well as adults, but they do come with unique considerations.

For instance, the onset of bipolar disorder is generally around age 25, but many kids can be misdiagnosed with it due to hormone changes. However, this only emphasizes the importance of learning how to recognize and deal with symptoms because, on average, half of mental illnesses appear by age 14, and three-fourths appear by age 24.

Growing up in today’s society can include an immense amount of pressure from all directions.

The social development of boys can be disrupted by pressures to become “manly” and suppress emotions, which can lead to social isolation and unhealthy ways of coping with stresses like punching things, picking fights and lashing out in a variety of other forms.

Girls suffer from far higher rates of depression and body image issues which aren’t helped by the fact that mental health issues can be dismissed as being overly emotional.

According to Sue Gunn, team leader of the Ellensburg Brief Intermediate team at Comprehensive Healthcare which focuses on children, families and adults, depression and other mental health issues in youth can relate to suicide in ways people might not consider with adults.

“The piece that’s hard with kids and adolescents is that they don’t see the result. They’re more impulsive, they don’t think about their mortality, they just think about the pain and wanting it to end,” Gunn said. “Granted, a lot of adults get to that point when they’re suicidal, but I think that just developmentally, kids can have an increased risk.”

However, Gunn also said that the advantage with kids and adolescents is that they usually live with families who can support and check in on them. However, not every parent knows how to recognize a mental illness or knows how to handle a mental health issue. Because of this, Comprehensive Healthcare works in collaboration with the Ellensburg School District to host Youth Mental Health First Aid workshops specifically for those who regularly interact with children such as teachers, parents and school counselors.

This kind of training is especially useful for people like Bryan Osborn, a juvenile probation counselor, because it helps him better understand the issues that his young clients are facing, letting him make better-informed decisions on crime prevention.

“Without this training, we can be slower to get kids the services they need,” Osborn said. “This (training) makes us more adaptable and importantly, better able to see what their perspective might be.”

Preventing crime before it happens is important, but those already in jail and prison also often need support systems and mental health care so they can more easily get back on their feet and re-integrate with society when released.

Comprehensive Healthcare and the county are working on this, as KVFR Deputy Chief Rich Elliot can attest to. Comprehensive Healthcare also has a transitional housing program, giving former inmates the temporary stability they need to get a job and hopefully move forward.

“(They’re) making a good effort and getting the inmates access to services,” Elliot said. “Because if you’re going to jail, chances are they’re not only in jail because they’ve committed a crime. Chances are they have a substance abuse issue or a mental health issue or they might have all three. They're probably going to come back if you don't fix the problem, and it's really super expensive to put people in jail.”

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