On Kimberly Reppâs office wall is a sign in Latin: Hic locus est ubi mors gaudet succurrere vitae. This is a place where the dead delight in helping the living.
For medical examiners, itâs a mission. Their job is to investigate deaths and learn from them, for the benefit of us all. Repp, however, isnât a medical examiner; sheâs a Ph.D. microbiologist. And as the Washington County epidemiologist, she was most accustomed to studying infectious diseases like flu or norovirus outbreaks among the living.
But in 2012 she was asked by county officials to look at suicide. The request led her into the world of death investigations, and also appears to have led to something remarkable: In this suburban county of 600,000 just west of Portland, the suicide rate now is going down. Itâs remarkable because national suicide rates have risen despite decades-long efforts to reverse the deadly trend.
While many factors contribute to suicide, officials here believe theyâve chipped away at this problem through Reppâs initiative to use data â very localized data that any jurisdiction could collect. Now Reppâs mission is to help others learn how to gather and use it.
New York state has just begun testing a system like hers. Humboldt County, Calif., is implementing it. Sheâs gotten inquiries from Utah and Kentucky. Colorado, meanwhile, is using its own brand of data collection to try to achieve the same kind of turnaround.
Following The Death Investigators
Back in 2012, when Repp looked at the available data â mostly statistics reported periodically to the federal Centers for Disease Control and Prevention â she could see that suicide was a big problem and that rates were highest among older white men. But, beyond that, the data didnât offer a lot of guidance. Plus, it lagged two years behind.
She returned to her bosses. âI can tell you who has the highest suicide rate, but I canât tell you what to do about it,â she recalled telling them. âItâs too broad.â
So she turned to the county medical examinerâs death investigators. They gather information at every unnatural death scene to determine the cause (say, drowning or gunshot) and manner (homicide, suicide, accident). Itâs an important job, but a grim one, and it tends to attract unusual personalities.
Repp mustered the courage to introduce herself to one of the investigators, Charles Lovato. âI said, âHi, my name is Kim and I was hoping to go on a death investigation with you.â And heâs like, âYouâre that weirdo that does outbreak investigations, arenât you?â And Iâm like, âYouâre the weirdo that does death investigations.ââ
The gambit worked. Repp accompanied Lovato on his grim rounds for more than a year. âNothing can prepare you for what youâre going to see,â she said. âIt gave me a very healthy dose of respect for what they do.â
She studied the questions Lovato asked friends and family of the deceased. She watched how he recorded what he saw at the scene. And she saw how a lot of data that helped determine the cause and manner of death never made it into the reports that state and federal authorities use to track suicides. It was a missed opportunity.
Collecting Data On The Dead To Save Lives
Repp worked with Lovato and his colleagues to develop a new data collection tool through which investigators could easily record all those details in a checklist. It included not only age and cause of death, but also yes/no questions on things like evidence of alcohol abuse, history of interpersonal violence, health crises, job losses and so on.
In addition, the county created a procedure, called a suicide fatality review, to look more closely at these deaths. The review is modeled on child fatality reviews, a now-mandatory concept that dates to the 1970s. After getting the OK from family members, key government and community representatives meet to investigate individual suicides with an eye toward prevention. The review group might include health care organizations to look for recent visits to the doctor; veteransâ organizations to check service records; law enforcement; faith leaders; pain clinic managers; and mental health support groups.
The idea, Repp said, isnât to point fingers. Itâs to look for system-level interventions that might prevent similar deaths.
âWe were able to identify touchpoints in our community that we had not seen before,â Repp said.
For example, data revealed a surprising number of suicides at hotels and motels. It also showed a number of those who killed themselves had experienced eviction or foreclosure or had a medical visit within weeks or days of their death. It revealed that people in crisis regularly turn their pets over to the animal shelter.
But what to do with that information? Experts have long believed that suicide is preventable, and there are evidence-based programs to train people how to identify and respond to folks in crisis and direct them to help. Thatâs where Debra Darmata, Washington Countyâs suicide prevention coordinator, comes in. Part of Darmataâs job involves running these training programs, which she described as like CPR but for mental health.
The training is typically offered to people like counselors, educators or pastors. But with the new data, the county realized they were missing people who may have been the last to see the decedents alive. They began offering the training to motel clerks and housekeepers, animal shelter workers, pain clinic staffers and more.
It is a relatively straightforward process: Participants are taught to recognize signs of distress. Then they learn how to ask a person if he or she is in crisis. If so, the participantsâ role is not to make the person feel better or to provide counseling or anything of the sort. It is to call a crisis line, and the experts will take over from there.
Since 2014, Darmata said, more than 4,000 county residents have received training in suicide prevention.
âIâve worked in suicide prevention for 11 years,â Darmata said, âand Iâve never seen anything like it.â
The sheriffâs office has begun sending a deputy from its mental health crisis team when doing evictions. On the eviction paperwork, they added the crisis line number and information on a county walk-in mental health clinic. Local health care organizations have new procedures to review cases involving patient suicides, too.
From 2012 to 2018, Washington Countyâs suicide rate decreased by 40%, preliminary data shows. To be sure, though, 68 people died by suicide here last year, so preventing even a handful of cases can lower the rate quite a bit.
Taking The Idea Elsewhere
Repp cautions that the findings canât be generalized. Whatâs true in suburban Portland may not be true in rural Nebraska or the city of San Francisco or even suburban New Jersey, for that matter. Every community needs to look at its own data.
Still, Jay Carruthers, who runs New Yorkâs Office of Suicide Prevention, saw the potential. âTo be able to close the loop and connect [the data] to prevention? Thatâs the beauty,â he said. This year, the state is beginning to test a similar system in several counties.
In Northern Californiaâs Humboldt County, public health manager Dana MurguÃa had been frustrated for some time that local prevention plans werenât making a dent. âI said, âWe donât need another plan. We need an operations manual.â Thatâs what I feel Dr. Repp has given us.â
Humboldt began using a Washington County-style checklist this year, and county officials have identified several unexpected touchpoints, including public parks and motels where people have died by suicide. Now, those sad facts can become action plans.
In Colorado, a different effort to reduce suicides also began with extensive data analysis. There, they realized that while youth suicide has understandably been a focus, the biggest numbers are among older men. Theyâve not only crafted materials specifically for men in crisis, but theyâve also created materials for specialized groups, such as veterans, farmers and construction workers.
âWhat was unexpected to me was how empowering these data would be to so many different people to make change,â Repp said â including Lovato and the other death investigators. âTo know that theyâre actually keeping the living alive is really powerful.â
IF YOU NEED HELP If you or someone you know is thinking about suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255, or use the online Lifeline Chat, both available 24 hours a day, seven days a week.
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.
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