
A Suicide Epidemic in Utah, and One Neuroscientist Thinks He Knows Why - jonah
http://mic.com/articles/104096/there-s-a-suicide-epidemic-in-utah-and-one-neuroscientist-thinks-he-knows-why
======
jrapdx3
Quite late here, and I wish I had more time to comment. I guess the main point
to make is the assertions about effects on serotonin/dopamine systems of
higher altitude locations, and effects of these messenger chemicals on
mood/cognition are vast oversimplifications of very complex multiple system
interactions.

To begin with, in important respects characterizing 5HT/DA as
"neurotransmitters" is not quite accurate. Certainly 5HT and DA play diverse
roles in the brain and elsewhere, but often act as _modulators_ of neuronal
firing patterns rather than primary signal transmission itself. Hence not
necessarily "excitatory" or "inhibitory" in a direct sense. Something like a
gate in an FET modulating current flow between source and drain.

We usually think of glutamate as the main excitatory neurotransmitter in the
brain, and GABA being inhibitory, but it's not a clean separation, since there
can be a range of effects on subsets of receptors.

Furthermore, 5HT, DA, and a host of other monamines and peptides have complex
interactions to up- or downregulate transmission in neuronal circuits.

It may be true that there are correlations among variables of altitude,
suicide, or even attentional disorders. However, not only does correlation not
imply causality, it's especially ambiguous when there is a potentially
unlimited range of contributors, perhaps far too many to factor in to the
results.

For instance, I live in Oregon where around 90% of the population lives in the
Willamette Valley, essentially at sea-level elevation. Yet according to the
graphics in the article, Oregon has a high (but not the highest) rate of
depression and suicidal behavior, known issues to be sure.

We do suffer other conditions like substantially northern latitude, widespread
Vitamin D insufficiency, economic stresses, and other factors to take into
account.

Perhaps the work described in the article could generate some interesting
hypotheses, but painting with such a broad brush seems overstating the case
and likely to be misleading.

~~~
LnxPrgr3
This over-simplification has made it hard to find out what my prescriptions
might actually be doing for (or maybe to) me.

I'm about to say things as a hopefully decently informed patient. Hopefully
it'll more useful than "serotonin = happy," but it'll probably contains
errors. Corrections and additional information would be greatly appreciated!

My GP prescribed two drugs at the same time: citalopram, an SSRI, to treat
depression, and hydroxyzine as a sleep aid.

I thought that was interesting because hydroxyzine is a 5HT-2a antagonist,
which seemed like it'd interfere with the SSRI. It took quite a bit of digging
to learn that it probably wouldn't, which still surprises me.

My current understanding is SSRIs play a long game—at first, the lower
reuptake rate extends serotonin's effect in synapses (but specific subtypes,
because boosting the wrong ones makes you puke), but then autoreceptors
(feedback mechanism for the transmitting neuron) undo that by causing less
serotonin to be transmitted in the first place. But then, eventually they
reset, and then the other end of the synapse gets to down-regulate its
sensitivity to serotonin, at which point the SSRI's done its actual job.

But the reading I did didn't leave me thinking researchers are terribly
confident that that's a complete explanation.

It would explain the side-effect profile though—especially the absurd increase
in anxiety. Treatment is increasing 5HT-2a activity, apparently intentionally,
when another drug is a potent anxiolytic blocking 5HT-2a activity. I quit
taking the hydroxyzine, but while I was taking it it seemed to be an SSRI side
effect off switch. It also made me a zombie the whole next day, which is why I
stopped taking it.

And of course, the biggest thing I learned: don't let the drugs be alone in
their battle against depression. Odds of successful treatment are much better
with the combination of drugs and therapy.

~~~
jrapdx3
Medications are tools not answers. All drugs have multiple effects most of
which have received little or no study at all. We are not fortune-tellers.
It's _impossible_ to predict exactly what effects a drug will have in a given
individual.

Hydroxyzine is an old drug, with antihistaminic, anticholinergic, and some
degree of 5HT2a antagonism. It can have moderate anti-anxiety effect, and may
reduce discomfort of opioid withdrawal symptoms. However, some people respond
poorly, or even become agitated with use of such agents.

While SSRIs block presynaptic 5HT reuptake, this is also known to be a
transient effect. Antidepressant action is associated with "downstream"
intracellular neuronal changes that are extremely complex and incompletely
understood. Specifically, 5HT2a effects are diffuse and connection to
particular symptoms tenuous at best. A quick look here should illustrate this
point:
[https://en.wikipedia.org/wiki/5-HT2A_receptor](https://en.wikipedia.org/wiki/5-HT2A_receptor)

Pragmatically, if a medication produces troublesome effects, don't try too
hard to "explain" the problem, but definitely don't suffer in silence. Talk it
over with the doctor and try other approaches. Psychotherapies can be
effective. I agree, it's not an "either-or" situation, rather "all-of-the-
above". By all means use the whole range of _effective_ and _tolerable_ tools
at your disposal.

------
nowarninglabel
The data seems to point towards a much more likely correlation, rural areas
seem to have a higher rate of suicide. How else does Oklahoma and West
Virginia get explained? It'd be much better to break the data down by county.
Even still, it's all probably just correlation. Another take:
[http://www.dailyyonder.com/booze-guns-and-rise-rural-
suicide...](http://www.dailyyonder.com/booze-guns-and-rise-rural-
suicides/2009/09/22/2358)

~~~
jschwartzi
The article implies that the location is causative, IE that living in
mountainous, rural regions causes depressive symptoms. You could also make the
argument that people with depressive symptoms might be drawn to mountainous,
rural regions.

I don't have any hard evidence or a citation to back this up, but someone once
suggested to me that the reason suicide rates are higher in Western,
"frontier" states is that people with mood disorders might tend to migrate
away from population centers. Population density is highest on the East Coast,
decreases through the Midwest, and reaches its nadir in the Rockies. Then it
increases again as you reach the West Coast.

I think we could explain their data using that correlation alone. Based on
what I'm reading from the article, I'd say my theory is about as strongly
supported as theirs based on the available evidence.

~~~
sswaner
I am not certain that population density reaches its nadir in the Rockies. In
those states (Utah and Colorado in particular), the population is clustered in
towns and cities along the Wasatch and Rocky Mountain ranges. In the midwest
there is a more rural distribution.

It would be interesting to look at suicide rates by population density at
level lower than state or county.

------
zb
I hope he has better evidence than what is presented in this article - a line
chart that should have been a histogram and which muddies the data by
inverting the supposed cause and effect; a study that shows a decline in the
psychological well being of a group of Marines after a month training at
altitude that is blamed (incredibly) on the altitude and not the training;
various anecdotes.

~~~
ndonnellan
I was confused by the chart. Higher suicide rates cause higher altitudes? If
the axes were reversed, the interpretation would seem very different (rate
shoots up for a small change in altitude, then levels off at higher
altitudes). Also the buckets are unequal (but maybe that's what vingtile
means. What is a vingtile, anyone?)

~~~
zb
I believe a vingtile is like a quartile, except that there are 20 of them
instead of 4 (vingt = 20 in French). So I'm guessing each bucket contains an
equal number of counties, rather than being an equal size.

------
raldi
I hate teaser headlines like this. How about something straightforward, like
"Low-oxygen air messes up serotonin / dopamine levels, can lead to suicide"?

~~~
freehunter
But that's not really a fact, is it? It's a hypothesis from one scientist.
There's enough sensationalism in science reporting already. Putting a complex
idea into one sentence that is wrong isn't any better than a teaser.

[http://xkcd.com/882/](http://xkcd.com/882/)

[http://www.smbc-comics.com/index.php?db=comics&id=1623](http://www.smbc-
comics.com/index.php?db=comics&id=1623)

------
Xcelerate
> When Renshaw peddled his altitude-suicide theory around the mountain states
> in 2008, he faced prickly reception. Renshaw heard that Utah's governor at
> the time, Jon Huntsman, was disgusted that the state would fund the anti-
> Utah research. Huntsman's staff did not respond to a request for comment.

You've got to be kidding me. Whether or not Renshaw's theory pans out, it's
"disgusting" to me that a governor would hide research just because it
interferes with the economy, rather than considering the well-being of his
state's inhabitants.

If I was a politician and there was research indicating something was (or
might be) causing medical problems, I would increase funding to figure out
what's going on and look for solutions. The laws of physics don't respect
political correctness; you can't just shove them under the rug if it hurts
your state's tourism.

~~~
js2
The NC GOP legislated against recognizing studies on sea level rise.
[http://www.reuters.com/article/2012/07/03/us-usa-
northcaroli...](http://www.reuters.com/article/2012/07/03/us-usa-
northcarolina-idUSBRE86217I20120703)

~~~
javert
I'm not sure, but I think it would be more accurate to say they decided not to
endorse a government panel's study (perhaps contrary to the default custom).

Which is actually the correct course of action: the government should neither
endorse or denounce scientific studies.

Rather, it should be up to real estate investors, insurance companies,
homeowners, etc. to decide the level of risk they face from rising water and
whether or not they want to take that risk.

And they should not all be required to go by the "official" North Carolina
projections. That is just silly. They should be allowed to use their own,
independent judgement.

------
curtis
This article was more interesting than I expected. Notably it proposes a
mechanism that I hadn't heard suggested before:

> Renshaw believes that altitude has an impact on our brain chemistry,
> specifically that it changes the levels of serotonin and dopamine, two key
> chemicals in the brain that help regulate our feelings of happiness.

------
metatation
It would have been interesting to see that heat map extend into Canada to see
if the trend along the Rockies continued as expected. I found the following
paper that at least anecdotally fits this theory:

[http://www.pembina.org/reports/10_suicide.pdf](http://www.pembina.org/reports/10_suicide.pdf)

Apparently Calgary is going through a suicide epidemic:

"suicides are the leading cause of death for boys and men 10 to 49 years of
age, ahead of murder, traffic accidents, and all other causes of death in this
age group"

Note that Calgary is at high altitude as well, roughly 3500 ft.

~~~
DanBC
When you restrict to men between 21 and 65 you find suicide is one of the
leading three causes of death, and often the leading cause of death, in many
places.

California has better than US average rates for death by suicide, but that is
because the death rate in older people is unusually low. When you look at
rates for younger people you find california does slightly worse than the US
average.

Suicide is, sadly, very common.

------
marincounty
1\. "Before training, the Marines reported more balanced mood levels than
average college-aged men. By the time they finished, they described mood
symptoms comparable to those of psychiatric patients. Ninety days later, they
were just as sad and agitated."

Maybe the physical and phychlogical beat down has something to do with mood?
Plus--the realization that the military is not quite what it promised?

2\. "Serotonin, an inhibitory neurotransmitter, helps stabilize emotions." I
guess that's fact these days? Maybe you should include all the studies, along
with the metadata, and make these magical claims?

3."By Renshaw's estimates, the brain makes about 20% more dopamine in the
mountains." That's quite an estimation on a neurotransmitter that we can't
even test for.

4\. "SSRIs are probably no more effective than prescription-plan tic tacs."
Maybe that should be the title of the article, and redact every other
sentence?

5\. "You tell me how Salt Lake City and Las Vegas have the same culture." You
can't use Nevada(maybe the most depressed state in the nation) as a control.
What happens in Vegas stays in Vegas--your liver, you savings, your dignity.

6\. "But 30 years after seasonal affective disorder got its name, SAD
sufferers plant themselves in front of light boxes to combat the winter
doldrums without anyone raising any eyebrows." Again, it's still just a
theory. I've never seen a Psychiatrist pull a light box out of his locked box
of sample medications.

7\. "When it comes to subjects as biologically and environmentally thorny as
mental health and suicide, Renshaw said, the answer is always more research."
Fine--apply for a grant and investigate the suicide rate among the Sherapas.

8\. I'm all for research, but keep it tight. Your audience is not as nieve as
we were in the 90's.

9\. Personally, I found the disparity of income in the mountians of Utah very
depressing. The wealthy moved in and prices from lift tickets, rent, eating
out all went up. Plus, it went from a rural, mainly blue collar community to
more of a buttoned down place where the people talked about investments/money
over the more important things in life.

~~~
sswaner
> 9\. I found the disparity of income in the mountians of Utah very
> depressing.

Ironic comment from "marincounty". In my experience growing up in Utah, it
seemed the wealthy people moving in all came from California.

------
acqq
The paper:

[http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.20...](http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2010.10020289)

"Altitude, Gun Ownership, Rural Areas, and Suicide

Namkug Kim, Ph.D.; Jennie B. Mickelson, B.S.; Barry E. Brenner, M.D., Ph.D.;
Charlotte A. Haws, B.S.; Deborah A. Yurgelun-Todd, Ph.D.; Perry F. Renshaw,
M.D., Ph.D.

Am J Psychiatry. 2011 Jan;168(1):49-54. doi: 10.1176/appi.ajp.2010.10020289.
Epub 2010 Sep 15."

------
ghshephard
This would seem to be one of the most easily controlled studies possible. Some
observations of various individuals at various levels of oxygen in hypobaric
chambers (some of them come equipped for extended living) would provide solid
evidence one way or another for this hypothesis.

Particularly in a controlled environment, assessing the individual's mental
health should be straightforward.

And I have to believe that GE likely even has a branch that manufactures
hypobaric chambers...

~~~
WiseWeasel
How do you control for the depressive effect of living for extended periods in
a hypobaric chamber? Seems like studying people living at different altitudes
would be easier, cheaper and less tainted by experimental environment factors.

~~~
ghshephard
"How do you control for the depressive effect of living for extended periods
in a hypobaric chamber?"

That's precisely what control groups are for. The idea behind using a
hypobaric chamber is that you control for 100% of everything, and _only_ vary
the oxygen levels - you could trivially simulate 2500 feet, 5000 feet, 7500
feet and 10,000 feet for a test group, while keeping the control groups at sea
level - and observe the differences.

The problem with testing people at "different altitudes" \- is there are so
_many_ other events that could be contributing (sunlight, exercise, diet,
etc...) - hard to eliminate confounding factors.

------
bikamonki
La Paz, capital of Bolivia, sitting at 12000ft, suicide rate: less that 2%.
Quito, capital of Ecuador, sitting at 9000ft, suicide rate: around 6%. I think
this article wants to start a new 'epidemic' for which 'expensive drugs' must
be taken.

------
batbomb
I was skeptical when I heard this, as I've grown up in high altitudes. So I
tried to do a check on a few other high altitude cities, and the results are
somewhat consistent.

Other cities which are high altitude with very high suicide rates include:

Denver, Colorado Springs, Albuquerque, Reno.

~~~
mc32
I'd be interested if this were also the case in other countries with high
plains populations like Tibet, Nepal, Bolivia, Switzerland, etc. Some places
have had stable populations for a long period of time, other populations (and
individuals) may be newer, relatively speaking --that might be something to
investigate as well, if it hasn't.

------
Codhisattva
The article is paid marketing content from GE. Just saying.

~~~
inDigiNeous
Exactly.

------
inDigiNeous
So yeah, okay, then Tibetan Monks and people living there should be very
unhappy. All the positive comments about ADD and ADHD medications in the
article, and the fact this is sponsored by GE makes me feel this is a paid
article made to promote more medication and move people away from the real
cause that is causing more and more suicides all the time, and that is, mood-
affecting medication. Do your own thinking.

Direct quote from the article: "There is such thing as too much fresh air" :D

~~~
sswaner
Sherpas and Tibetans have thousands of years of natural selection to develop
increased survival ability at altitude. Non-native residents of the mountain
west states have only been there for no more than 167 years, having mostly
immigrated from lower altitude regions.

~~~
gwern
Right, and some of the genetic variants have even been nailed. Since we can't
randomize people to move to Utah (well, the Mormons and Air Force clearly
could by randomizing part of their admissions, but it's unlikely they'd
cooperate) and since the hyperbaric chambers offer confounds of their own
(either people aren't in there long enough to matter or any resulting
depression may be due to confinement), the genetics angle seems like the best
way forward: collect genomes along with psychiatric status and altitude, and
using GCTA, I think, look for an interaction between altitude & depression; if
you can establish a genetic contribution to high-altitude but not low-altitude
depression, that strongly supports the claim that altitude can cause
depression.

------
peapicker
As one who has lived at 5500ft elevation or higher for all but of few of my
40+ years, this is pretty interesting...

I still wouldn't trade the Rockies for anything.

------
ajarmst
Couple of warning signs: (1) Article is actually a paid advertisement, and
doesn't pretend to anything like peer review. (2) "In addition to the
statistical evidence, Renshaw collected anecdotes that supported his
developing theory." Seriously?

As we don't have anything like a useful theory of what depression is and the
details of how neurotransmitter levels are connected to mood, especially over
the long term, he's really jumping to conclusions. His statistical correlation
is weak, and correlates to a lot of other things (maybe Republicans cause
suicide, or proximity to harbors protects you from suicide). He needs a causal
mechanism and a LOT better data before this is anything like a useful
hypothesis. By the way - lets note that Switzerland's suicide rate is
considerably lower that France, and half that of Japan (most of whose
population centers are near sea level).

~~~
ajarmst
Addendum: I also note that Pakistan, Peru and Nepal report very low suicide
rates versus world averages. Usual questions about what "report" means, but
one would probably think they would discuss this apparent problem with their
theory.

------
EGreg
I just wish more than One neuroscientist knew. I've seen such headlines a lot
about science, they are sensationalistic but how often does this "one
scientist" get the establishment to accept their work through the regular
channels - peer reviewed journals - and how long dods it take?

------
brianstorms
This is a case of SA;DR. Sponsored article, didn't read.

I wanted to read the article, honest I did. But as soon as I saw the General
Electric (GE) logo smack-dab in the _middle_ of "Brain.Mic"'s own logo (who
the f%^$ does that!?, what self-respecting company, particularly a journalism
publisher, DOES that!?), I tuned out. I won't trust a publication that sells
itself out that way, and consider the content of the article suspect. Sorry,
but that's how I roll.

------
gtani
Read the article, thought Eureka. I moved to SLC to train as an adaptive ski
instructor and immediately had those altitude affects, loss of appetite and
sleep, irritability etc, that were familiar from lots of time spent sleeping
at mountain altitudes (7-8k feet above sea level, generally). Being at about
4300 feet above sea level or so on the east side affected me heavily, tho i
figured the native population just got used to it.

(Aside from that, I love Utah

------
ajarmst
One wonders how this particular correlation rates in comparison with other
better-known correlations: youth, maleness, poverty, stress, solitude, access
to firearms. I suspect that it would kind of disappear into the noise. I
wonder if investigating the effect of poverty (Utah is 40th in per-capita GDP
by state, and has the 4th highest unemployment rate) and access to firearms in
this particular case might be a bit more diagnostic.

------
briantakita
The article seems to be in favor of SSRIs (e.g. Prozac). However, SSRIs have
also been linked to suicidal & violent behavior.

[http://www.drugwatch.com/ssri/suicide/](http://www.drugwatch.com/ssri/suicide/)
[http://www.theguardian.com/science/2000/may/22/drugs.uknews](http://www.theguardian.com/science/2000/may/22/drugs.uknews)

------
kristianp
Sorry, I'm not reading a webpage with a busted layout like this:
[http://imgur.com/TsN7sUg](http://imgur.com/TsN7sUg)

The top non-scrolling region is quite large, and then they add on a facebook
and twitter curved thing as well? Infuriating! Am I the only one seeing this?

------
MrBra
It's because the higher you live, the greater you will see the beauty of the
world and so, the less you are already self realized, the more you will feel a
bigger discrepancy with it. And it can hurt.

------
orasis
I live in a ski town, this might explain why my family tends to sleep so much.
I try for 10+ hours per night, which would make sense if I need extra time to
replenish seratonin.

------
kinleyd
Interesting theory, but one which my guess is unlikely to hold up if the study
is carried out it in really mountainous, high altitude areas.

------
Zaephyr
A very interesting article. For me two key statements come toward the end.

"Did you know that at high altitude, the brain goes through metabolic changes,
and some people can adapt while others can't, based on their DNA?"[Renshaw]

"Renshaw, too, is confident his findings are beyond the realm of a fluke, but
he isn't willing to dismiss other explanations for the suicide-altitude
connection, including studies on gun access. Multiple overlapping factors, he
says, are likely in play."

------
wfjackson
Did they check the lithium levels in those places?

[http://www.nytimes.com/2014/09/14/opinion/sunday/should-
we-a...](http://www.nytimes.com/2014/09/14/opinion/sunday/should-we-all-take-
a-bit-of-lithium.html)

~~~
gwern
See
[http://www.ncbi.nlm.nih.gov/pubmed/23733285](http://www.ncbi.nlm.nih.gov/pubmed/23733285)
:

"The correlation results showed a negative association between lithium levels
and altitude. The regression confirmed a negative association of lithium
levels and suicide mortality. Altitude was found to be positively associated
with suicide mortality. On the other hand, lithium effects on suicide
mortality were found to be moderated by altitude. In lower altitude regions
the effect turned out to be negatively related to suicide mortality, while
lithium had a positive association in high-altitude regions. These results
provide evidence for the fact that the relationship between lithium, altitude
and suicide rates is more complex than hitherto assumed."

