There’s a romance to Montana that beguiles. Ask anyone to define the state and they’ll mention the mountains, the wide-open spaces, the stoic, hardworking cowboy culture.
Like all great places, though, it comes with trade-offs.
Those distances, that stoicism, the frontier pockets of the state where jobs are scarce can be overwhelming.
And it may be why the state that residents regard as the “last, best place” has been near the top in the nation in the rate of suicide for 35 years.
"Montana's suicide epidemic is a public health crisis,” said Matt Kuntz, executive director of the Montana chapter of the National Alliance on Mental Illness.
During 2010, at least 227 Montanans killed themselves. In 2011, the number was closer to 225. That’s about 22 people per 100,000 residents, nearly twice the national average.
The victims are military veterans, American Indians, senior citizens and teenagers. Often, they are depressed and hundreds of miles from the nearest mental health professional. Even where they can get help, they tend to "cowboy up," afraid their illness will be seen as weakness.
Not only has Montana's suicide rate hovered in the top five nationally for decades, in the past few years it has gone up. That spike is reflected across the nation.
In the past five years, the state's suicide rate has crept from 20.1 per 100,000 people to 22.5. Nationally five years ago, the rate was 10 people per 100,000. Today, it's closer to 12 people per 100,000.
And those are the ones who succeed. A recent federal study suggests that 8.3 million Americans — 3.7 percent of all adults — have serious thoughts of suicide each year; 2.3 million make a plan, and 1.1 million attempt suicide.
The result is an estimated 37,000 suicide deaths annually, and the Rocky Mountain region shoulders the bulk of the deaths.
In Montana, every one of the 452 Montanans who killed themselves last year had a face, be they a troubled father, a confused teenager, or a lonely, elderly widow.
The majority who took their lives — 77 percent, or 350 — were males. The victims came from all age groups, although most of them — 91 people — were 55 to 64. Another 88 were 45 to 54, and 75 of the victims were between the ages of 24 and 34.
Another 5,600 Montanans — an average of about 15 per day — attempted to kill themselves last year.
“We’ve got a lot of hurting people,” said Jim Hajny, executive director of the Montana Peer Network, a nonprofit organization of individuals who are in recovery from mental illness, substance abuse or both. “We have to get at this.”
Suicide figures vary from community to community, with the bulk of them occurring in Western Montana and pockets on the eastern edge of the state.
The highest rate of suicide in the state is among American Indians, 27.2 per 100,000; followed by Caucasians at 22.2 per 100,000. For 2010-2011, there were 38 American Indian suicides, compared to 410 Caucasian suicides. American Indians make up 7 percent of the Montana population.
There are specific risk factors for American Indian communities that contribute to their higher suicide rate, including high unemployment rates, substance abuse, alienation, and varying cultural views on suicide. A major issue among the American Indian communities is the separation taking place between generations, said Karl Rosston, Montana’s suicide-prevention coordinator. Traditionally, the youth have looked toward the tribal elders for guidance and identity.
“However, in recent generations, there has been a breakdown in this guidance,” Rosston said. “Subsequently, American Indian youth appear more hopeless and unsure of their place in their culture. This may contribute to the high number of suicides among American Indian youth.”
The underpinnings of Montana’s problem are considered universal among many, though not all, health experts on the local, state and national level.
Many of the self-imposed death sentences stem from a Western independence, where acknowledging personal problems may be viewed as contrary to the cowboy way, said Drew Schoening, a psychologist at the Montana State Hospital in Warm Springs.
“So, they go untreated and we know untreated mental illness results in higher rates of premature death, accidental death and suicide death,” Schoening said.
The prevalence of guns in the state compounds the problem, not only because they're handy, but also because they're generally fatal. Victims are less likely to survive an attempt and then seek help. Most of the state’s victims last year — 291 — used a gun.
The second and third most common methods were suffocation/hanging and poisoning/overdose. Other methods included drowning, cutting and piercing, jumping from heights, burning, and motor vehicles.
Montana ranks third in the nation for per capita gun possession, according to an analysis by the news website The Daily Beast of the FBI's National Instant Background Check System.
Kentucky is first, followed by Utah at second, with Wyoming in fourth and Alaska fifth.
People who live in areas with high concentrations of guns are more likely to die by suicide, according to a 2007 study by researchers at the Harvard School of Public Health. The study looked at the 15 states with the highest firearm ownership and found that twice as many people were successful in committing suicide in those states compared to the six states with the lowest firearm ownership.
Another leading cause is considered to be the social isolation that comes with living in Montana. The state has 6.7 people per square mile, according to the 2010 Census. The national average is 88.7 people per square mile. Neighbors are often few and far between, reducing the possibility for social contact or communication. The isolation can contribute to many emotional, behavioral and physical disorders including anxiety, panic attacks, eating disorders, addictions, substance abuse, depression and violence.
“That may be because when somebody gets into a difficulty, they don’t have friends and family to go to (who can) help them with that,” said Dr. Alex Crosby, a medical epidemiologist with the Atlanta-based Centers for Disease Control and Prevention. “Those who have a stronger network of social support have a lower incidence of suicide.”
Use of drugs in Montana, especially alcohol, is also widespread. That is significant because nationally about 33 percent of the people who die by suicide have alcohol in their system, Rosston said.
Montana counties with the highest suicide rates also have high unemployment and high rates of poverty. Twenty percent of Montana’s youth live 100 percent to 200 percent below the poverty line.
The shortage of mental health professionals and mental health treatment facilities in the state is also well-known and widely reported.
As of Nov. 1, there were 146 licensed psychiatrists in Montana. Patients can wait anywhere from two weeks to three months or longer to see a psychiatrist. In some areas of the state, there is one psychiatrist serving a vast, multicounty area.
There are about 50,000 psychiatrists in the United States-- too few to serve all the patients who need help, especially in rural areas, according to the American Psychiatric Association. About half of currently practicing psychiatrists are over the age of 55, and many will soon retire.
“How do you provide service if you’re trying to cover 1,000 square miles?” asked John Glueckert, administrator of the Montana State Hospital in Warm Springs. “It’s very difficult.”
In the absence of psychiatrists, patients sometimes are referred to lesser-trained therapists.
“They can assess the gravity of the situation,” said Dr. Bruce Swarny, a psychiatrist at Glendive Medical Center. “Is it the ideal set-up? I don’t know, but it’s the best we can do.”
NAMI’s Kuntz said it is unrealistic to think every Montana town will ever have its own psychiatrist. Still, he believes there is an opportunity to infuse communities with the help they need.
“If we had psychiatrists or psychiatric nurses everywhere that Wal-Mart thinks there’s enough people to set up a store, we’d be a little closer,” Kuntz said. “If you’re in a little, tiny Montana town and you drive to Miles City to go to Wal-Mart to get cheap groceries, then that’s the town you would go to for your mental health treatment.”
Most residents in the far corners of the state don’t have access to mental health professionals, forcing them to travel hundreds of miles to seek help. In one extreme case, a person traveled more than 400 miles one way, much of it on secondary roads, to receive mental health services in Bozeman.
“The stigma for reaching out in their own community was so extreme, it wasn’t an option,” Hajny said.
Despite all the well-reasoned explanations for the runaway number of suicides, there is no one-size-fits-all reason.
“Every person I talk to would probably have a different, unique reason for wanting to take their life,” Schoening said. “That’s why we have such a struggle at trying to help people through this. … I think the true scientists are still trying to figure it all out.”
Kuntz said the reasons for suicide go beyond the idea of the state having a “cowboy culture.”
“It’s not that easy,” Kuntz said. “Personally, I think we need to be comfortable with the fact that no one really knows.”
Crosby concurs. “Most researchers that look into the area of suicide believe it is not the result of just one factor.”
Suicide is so common that some see it as the solution to divorce, family dysfunction, custody disputes and financial woes. It is considered acceptable when an individual's burdens mount, said Crosby, the medical epidemiologist with the Centers for Disease Control and Prevention.
Though it's difficult to place a dollar figure on the impact of suicide, the fact remains that the economic burden of suicide falls on everyone in the state. The total lifetime medical and work loss costs of suicide in Montana was at least $279.4 million during 2010, according to data available from the CDC.
The price tag includes expenses associated with suicide and its aftermath, including cost for the medical examiner/coroner investigations, emergency department treatments, hospitalizations, and nursing home care. It also includes costs associated with future productivity losses (i.e. lost wages, fringe benefits and lost household work) due to premature mortality. Not included in this figure is the cost associated with property damage, pain/suffering, loss of quality of life, litigation, and the impact, emotional and otherwise, of each suicide on surviving family members, friends, and other loved ones.
So dire is the problem that in 2007 the Montana Legislature passed Senate Bill 468, which created the statewide suicide prevention coordinator position to spearhead the Department of Public Health and Human Services suicide prevention activities. The program’s annual budget is $400,000 with $200,000 going to the state suicide prevention hotline.
Rosston said that to reduce the suicide numbers it is going to take a cultural shift in thinking.
"We need to begin to challenge our traditional perceptions of how we view depression as a weakness or that we are a burden to our families if we are depressed,” Rosston said. “We need to make it OK to talk about depression and make it OK to ask for help. This is not a quick fix. If it is a generational problem, it is going to take generations to fix."
It is not an impossible mission, he said.
“I wouldn’t be in the job if I didn’t think something could be done. I think it’s just going to take time.”