Positive association between altitude and suicide in U.S. counties
ncbi.nlm.nih.gov
ncbi.nlm.nih.gov
"Together, the stray statistics and stories about life out west tipped off Renshaw to a common culprit: altitude-induced oxygen depletion. [...] Renshaw believes that oxygen-poor air tampers with brain chemistry, leading to a drop in serotonin and an uptick in dopamine."
Also, when I first moved from Philadelphia to a village in New Mexico at 6000', I remember reading that I should plan on a 3 phase adapative process that would take as much as 9 months to complete. This makes me give less weight to things like the 2005 Marines study that Renshaw cites, which only continued for 90 days.
I should stress that I'm not doubting the statistics, just the proposed mechanism ("low oxygen air"). On the other hand, "varying ability to fully adapt to lower oxygen levels" seems more plausible.
Same blood oxygen level as a sea level human means same quantity of oxygen getting to the brain.
>Even if oxygen levels are identical once you get to the blood stream, it can cause many changes further up the process.
What mechanism could possibly cause this? The brain is getting all the oxygen it needs.
I have no idea, but I was unaware this could only be caused by oxygen failing to reach the brain.
on average, but you can get a population effect from "some small portion of the population has smaller or disease compromised lungs or just sleep apnea, and THOSE people commit suicide at a higher rate at high altitude".
The "our lungs are big enough" only works if you control for the cases where they aren't.
I'd hoped that things like genetic screening would uncover that some cases where studies showing that eating/avoiding Foo has a small positive or negative effect turns out to actually be an enormous effect in a small sub-population... but so far we don't appear to have identified too many of those.
Your cells cannot measure environmental O2 levels - only what is available from the bloodstream. Ergo, if sufficient adaptation has taken place - and it may not have - then as far as the body is concerned, there is no depleted O2 environment.
This tiny little caveat is the entire point of my comment. Happy to converse about other stuff, but it's a tangential topic at best.
>You'd need to show it because for O2 levels to matter, it would need to be the O2 levels experienced by cells that are different.
Right, and some of your body's cells are experiencing it differently. How... else would your body know to respond?
Renshaw appears to be suggesting/hypothesizing that there is some universal "low O2" effect that leads to higher rates of suicide.
I'm saying that this seems unlikely, given that in fully adapted individuals, the cellular environment does not experience low O2.
Of course, in non-fully adapted individuals (either because they are still adapting, or because genetic/physiological factors prevent it), this would not be the case.
But that still says that there's no "general" low-O2 mechanism that is affecting anyone who lives at altitude. It only suggests that there maybe a low-O2 mechanism that affects some individuals. Whether there is a correlation between suicide rates and altitude adaptation doesn't appear to be easily established.
Then a mechanic shows up a lever you can pull that alters the way the engine intakes and processes O2. You move it a bit, and all of a sudden, the engine now functions just as well in 19.2% O2 as 20.9% O2.
Now imagine that the engine can measure its own performance, and can move the lever itself ...
I am much older now and a couple years ago I retired/moved from about 600' MSL to 6300' MSL and it took about a half of a year for my body to adjust including some pain in my legs with some associated popping and other weird pressure like feeling similar to what I had when younger but it took longer to go away. Probably too many decades behind a computer and not enough walking. I've had no feelings of self defenestration.
Among other things, Acclimatization involves producing more blood-oxygen carrying capacity (or less if you go back to sea level), which is an absolute measure, not a relative one that the oximeters would pick up.
I've been here 4+ years now, and other than being 4 years older and just coming out of a sedentary 3 year period, I notice zero effects of living (and running, cycling, swimming, hiking) at altitude. Can't say any more than that really.
I know you said that it has to vary between multiple individuals at altitude, but it's unclear to me why.
Don't we just have to show some individuals don't ever get back up to the same blood oxygen levels?
I would imagine that there are a variety of potential genetic differences that could generate a wide range of altitude-adaptation differences.
I think there are a few other similar sites.
Preferably low-grade to rule out gross pathology.
I am going to assume that in urban vs rural areas that is a similar effect from air pollution.
But all my doctors have been inclined to give me pills for depression, and aren't interesting in exploring the relationship with O2.
Elite, and dedicated amateur, athletes will develop specific breathing routines to increase O2 availability in support of increasing their VO2 Max but even for sedentary (so, typical) adults practically any form of mindful breathing coupled with higher-than-typical physical exertion will increase oxygen availability.
Their breathing routines not coincidentally almost always mirror some kind of yogic breathing technique.
Yogic breathing in hypobaric environment: breathing exercising and its effect on hypobaric hypoxemia and heart rate at 3,650-m elevation
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8413908/
Effects of Slow Deep Breathing at High Altitude on Oxygen Saturation, Pulmonary and Systemic Hemodynamics
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3495772/
When you meditate or do yoga asanas (poses) with a focus on your pranayama (breathing) as a matter of routine for long enough you subconsciously start performing yogic breathing all of the time.
Walking is just irrefutably, no-citation-needed, good for you.
I would make these claims instead:
- people at altitude spend more time indoors avoiding extreme weather caused by the altitude
- o2 levels to the brain are not significantly different for people whose bodies have adjusted to the altitude already
- people who live at altitude are more likely to be more active
- cities in modern western countries are largely clean of major sources of air pollution (one of the few things NIMBYs are good at)
- cities in developing countries (eg. Pakistan, India, China) are incredibly different
- rural areas are largely clean of air pollution except in hotspots (eg. factories and mines)
- your doctor likely doesn’t do actual science (“explore relationships”), but rather just disseminates the evidence that others have already recorded
- your doctor likely works in the USA where we pay fee for service. Maybe you should look at how single payer systems align healthy patient long term outcomes align with the single payer total costs.And that's excluding the light and noise pollution that are inevitable in urban areas. Yeah, living in a rural area is pure hell.
Or when we build the highway, we don’t raze the homes of the elite/wealthy/well-connected to do it, we do it in “bad neighbourhoods”
Or indirect effects: factories move/build next to the new highway (ease of moving materials+density of employees+ease of commuting because of the highway), contaminating the neighbourhood.
Source, in dutch: https://www.hln.be/milieu/omwonenden-a10-snelweg-leven-79-da...
"The serotonin theory of depression has been one of the most influential and extensively researched biological theories of the origins of depression. Our study shows that this view is not supported by scientific evidence. It also calls into question the basis for the use of antidepressants."
https://www.ucl.ac.uk/news/2022/jul/analysis-depression-prob...
2. A theory being debunked does not mean it's "just a marketing gimmick"
3. The serotonin theory being debunked does not mean "chemical imbalance" is totally exonerated
Great article though, thank you for sharing. Here's the paper itself for anyone interested (AFAICT it is oddly not linked in the UCL article?): https://pubmed.ncbi.nlm.nih.gov/35854107/
Serotonin theory being debunked does not mean “chemical imbalance” is totally cleared from blame
Seems clear enough to me, but noted for the future!
[UPDATE]: Looks like I'm getting downvoted by people who cling to their meds. Try physical activity and adjusting your self-talk. Try having goals and making steady progress toward them. What you need doesn't come from a pill, it comes from living life.
Fuck off. Imagine telling someone with astigmatism that they don't need a physical modification and augmentation to their bodies, but rather "to live life", whatever that means.
Meanwhile, after decades of swearing I didn't need a pill, I didn't want a pill to "change" me, etc, I got on pills, and my life actually works. I rode a rollercoaster for the first time in decades the other day, zero butterflies in my stomach, zero panic or anxiety, zero inappropriate fear. I'm likely only alive today BECAUSE of medication.
The whole point behind how new medications are tested are that we often don't have a great understanding of HOW a medication works, but that doesn't matter, because it demonstrably works in some percentage of people, and for those that it doesn't work for, often another medication might.
So, with zero respect because you are actively harming people, Fuck right off.
Although I've resigned myself because I know that people will often not acknowledge and have empathy and understanding towards a condition if they haven't experienced it in their own skin.
It's depressing, but it seems to be part of the human condition.
And it is all about my genetics. I am a lowlander by heritage, a Sami from Finland, and I carry genetic changes in NOS1AP that lower my ability to make nitric oxide at altitude. But the other factor is polymorphisms in GCH1, a gene linked to altitude adaptation:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5460084/
See GCH1 is the enzyme critically needed to make something called tetrahjydrobiopterin (BH4), and BH4 last at the center of the creation of all the catecholamines, like dopamine and serotonin, but also Nitric Oxide.
https://www.researchgate.net/figure/Fig-1-Tetrahydrobiopteri...
They make a drug called Kuvan which is a BH4 analogue but they only sell it in the EU because they want those of use with mental illness in the U.S. to suffer.
But zinc will increase the activity of GCH1 and alleviate many of these issues for me.
https://www.sciencedirect.com/science/article/abs/pii/S00062...
It has nothing to do with low oxygen, but rather low catecholamines.
https://www.washingtonpost.com/history/interactive/2023/smit...
Sometimes I wonder if my mental illness, and my utter disgust of capitalism, is from the legacy of trauma in my lineage.
What is even more interesting is that my senior thesis paper was on a man named John Collier who was the head of the Indian Affairs Bureau in the early 1900's and really into eugenics. He wanted to ship Indigenous Americans all over the country so we could all get their genes and be more like them. Funny that wikipedia called him an "advocate"!
Any correlation with blood pressure regulation?
> Controlling for percent of age >50 yr, percent male, percent white, median household income, and population density of each county, the higher-altitude counties had significantly higher suicide rates than the lower-altitude counties. Similar findings were observed for both firearm-related suicides (59% of suicides) and nonfirearm-related suicides.
So (median) income has been considered, in case anyone is wondering.
Here’s a map of suicide rate in Italy. Note the north has higher rate of suicide than the south. The north of Italy is much richer than the south.
https://www.reddit.com/media?url=https%3A%2F%2Fi.redd.it%2Ff...
Mountain towns have about the biggest class dichotomy that I've seen anywhere between the wealthy and the "help." Unlike many other places, they're all in close proximity.
It's poor science at best, if you can't control variables then the whole thing is next to useless, which happens a lot these days. At the end you have correlations, not causations
Bogus science can move us forward, but also backwards.
The response to a paper ought not be, “This paper is bogus because they didn’t control for all variables.”. If the paper is bogus then give reasons for why this is the case. Was the statistical analysis wrong? Are there reasons why this can’t be true? Is this new information worthy of further investigation?
It’s sloppy thinking to say it’s a bad paper without having studied the issue and the data.
Retrospective studies are fairly rife with poor science. They are heavily limited by the data collected and can be easily manipulated by changing different controlling factors. While I wouldn't describe the paper itself as bogus. The title certainly takes a lot of liberties.
You'll always have to augment statistical associations with further knowledge of the world, so you can get to causes.
Tragedy and desperation mostly kick in at the bottom of the distribution, especially in the US where median income is in most places not completely awful.
So controlling for the bottom 20th percentile or something makes way more sense.
Then you start to drive out of town, and there is N O T H I N G. I mean, from SLC, there's Ogden and Provo, maybe Park City. From Denver, there's Colorado Springs and Fort Collins. Once you get past those, it's a long way to the next anywhere.
So are they isolated? Depends on how you define isolation. Does that particular kind of isolation affect depression and/or suicide? No clue.
Plus, depending how you measure it, "population density" can be a nearly useless metric. County-level population density is spread widely over 3 orders of magnitude. The smallest county has 64 people and the largest has ten million.
To me this panned out in two ways:
* There really wasn't a lot to do outside a 10 mile radius. Anything worth doing was 1 to 2+ hours drive (often more). That meant nearly everything we did was in the small city we lived in.
* Travel was frustrating. We essentially had to pay a 3 hour driving tax on every trip we took.
In other words, despite living in a "suburban" density city (with some urban density areas), it was really how our city was positioned relative to other cities that determined it's feeling. It wasn't large enough to explore internally.
Consider this simplified example.
11 areas. 10 of these are isolated and have 10 people living in each area. The last area has 100,000 people living in it. Of those 10 areas, 9 have 0 incidents, and 1 has 1 incident. In the 100,000 area, there are 100 incidents.
Not controlling for the population: The populated area has 100 incidents, the isolated areas have an average of 0.1 incidents. A 1,000 times difference. Populated area is much more dangerous.
Well that's obviously the wrong way to look at the data, so lets account for population:
Isolated areas have a rate of 1 per 100 population, populated areas have a rate of 1 per 1,000 population. A 10 times difference, in the opposite direction. So now we have established a link between being isolated and have more incidents, but we don't know why.
We still haven't controlled for the impact of population density on incident rates. We need much more data to solve this, as with the given information the result would be "Isolated areas have 10 times the risk of incidents" and then controlling for that factor we would see no more trends in our data. If we added thousands of more areas with different levels of population, calculate the per capita rate of incidents in each population, and then create an analysis of how populate density relates to incident rates, we could then control for both factors. The catch is that this last step is more difficult without enough data and often researchers aren't able to isolate single individual items to control for because they correlate too strongly with other issues.
Increased altitude has recently been shown to have a protective association with certain medical illnesses, with apparent decreases in mortality among patients with end-stage renal disease receiving dialysis (Winkelmayer et al., 2009), coronary artery disease (Baibas et al., 2005; Faeh et al., 2009), and stroke (Faeh et al., 2009). By contrast, increased altitude may enhance psychiatric disorders, such as panic attacks (Roth et al., 2002).
AND
Controlling for... population density of each county
"Despite a negative correlation (r = −0.31, p < 0.001) between county altitude and the all-cause mortality rate, there was a strong positive correlation (r = 0.50, p < 0.001) between altitude and suicide rate at the county level (Fig. 1)."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5460084/
Not all of us were meant to live at higher altitudes.
But they do mention that they "[controlled] for percent of age >50 yr." Does that imply that, per county, they excluded high-elevation suicides that wouldn't have happened at lower elevations, using known mortality rates for common causes-of-death for age > 50 individuals?
I'm sure the answer is in the paper somewhere, but I need to get back to work. :-)
I believe the leading hypothesis is that the higher oxygen at lower altitudes causes more oxidation.
Citing the exception to try to disprove the rule generally doesn't work out so well.
Most high-elevation counties in the US are situated in extremely large high elevation regions.
Even knowing things like where the final act was committed (at home, not at home, etc) would be super useful, but that data is hard to come by i'm sure, especially at scale.
High rises have their own associations with mental illness. I don’t know if anyone has ever looked at pure altitude as possible effect.
Anecdotally, a 1:5 relationship is about ideal, for every x5 700 square foot apartments, there should be 700 square feet of common space. Think 5 doors attached to one courtyard that itself is about the size of an apartment.
From a for-profit point of view, this is a waste of construction cost.
I grew up in a mountainous region where the ridges separate the valleys. If your friend lived a mile away, it might take 20 miles of driving to get there because of the separation.
I wonder if they've measured that people who are very isolated have more suicide?
Lesotho is the country with the highest low point (1,400 metres / 4,593 ft) of any country in the world.
More than 80% of Lesotho lies above 1,800 metres (5,906 ft).
> Although there was a negative correlation between county altitude and all-cause mortality (r = −0.31, p < 0.001), there was a strong positive correlation between altitude and suicide rate (r = 0.50, p < 0.001).
To paraphrase the question: since total mortality must be exactly 100%, is the increase in suicides just an automatic and meaningless numeric compensation for the decrease in all-(health related)-cause mortality?
The answer to that is somewhere within their methodology on controlling for age. But I was unable to grasp the jargon on this one.
I suspect in the future death by choice, in a palliative setting may go up. Though with the current waves of deregulation, maybe we're headed for more industrial accidents.
But as for the article. Places that are high up, are cold and isolated and people are social beings.
Can you point to the study that makes this claim without controlling for other health issues? Otherwise, you're just making stuff up, which is worse than what you accuse the scientists of.
https://journals.plos.org/plosmedicine/article?id=10.1371/jo...
Does it? Can you link to the study?
Suicide rates are up in absolute sense.
What happens if we control for distance to a body of water? I suspect that has a more direct impact on wellbeing.
> strong positive correlation between altitude and suicide rate (r = 0.50, p < 0.001).
That is not strong. Put differently, altitude only explains 25% of the suicide rate. I know some fields have lower thresholds for what they consider strong, but still. An effect, sure, but I'd bet on this pointing to something else.
Not familiar with the demographics vs geography here, but how do typical high-altitude places look like in terms of society? They control for median household income and population density, but what about social attitudes? (are these places more rural? more traditionalist?), number of ways people can engage socially (say, cultural events, clubs, and so on), does their diet differ? etc etc.
Also, maybe putting the year (2011) in the title might be good. There may be more recent work / reviews.
EDIT: I forgot to mention diet
This paper gets a lot of scrutiny, but it's been out for over a decade and hasn't been debunked or explained. I've been mulling over this one for awhile, and have had several conversations with reasonably informed individuals in related fields. There's a lot of theories, many of which are explored in the comment section here. If you strongly believe in a theory, I'd like to remind you that this is a line of inquiry that could have life saving implications.
I assumed culture was a large component to this, but I don't know enough about South Korea to compare its high altitude people to those of the US. Maybe it is something environmental?
I've only read the abstract (so I don't know if my question is answered somewhere in the full report), but does anyone have any insight about why newer data wasn't included in this study?
Also, because urban environments in the US west are relatively new, they tend not be found "between mountains" in the same way that the centuries old cities across the Alps etc. are. The large population centers (Denver, Salt Lake City, Albuquerque) are built in large, open flat areas, and many of the midsize cities are not really surrounded by mountains in the way that equivalent European or other non-American cities often are.
I would guess that altitude and longitude are not correlated globally (at least I don't know why they would be) but in the US I generally associate altitude with snow.
Which makes sense: it can be isolating if everyone around you seems to be thriving and you aren't.
Cold is easier to deal with than dark and gloomy when I go to work and dark and gloomy when I come home.
TLDR: Author researches obesity epidemic in US, finds out negative correlation between obesity and altitude and comes to a hypothesis that it may be due to possible higher concentration of lithium in the water in lower areas
Wonder if this is also the reason in this case since lithium is an antidepressant
It almost certainly causes depression, not to mention death, and is highly correlated with altitude.
Regardless, high altitude cities like Denver, Salt Lake City, Reno or Boise are neither particularly cold or cloudy when compared to other US cities.
“at high altitudes, atmospheric pressure is reduced, and oxygen is less available (commonly referred to as the air being “thinner”). This has a couple of effects on air quality for the people in the area. First, combustion engines perform less efficiently than they do at lower altitudes, causing an increase in emissions. Second, UV rays from the sun have a greater impact at high elevations, leading to an increase in photochemical smog, the result of airborne pollutants reacting with sunlight.” https://www.aprilaire.com/blog/altitude-and-healthy-air-air-...
Random 5 seconds search:
https://academic.oup.com/innovateage/article/2/suppl_1/19/51...
> Follow-up analyses showed there was a significant (p = .005) relationship between population density and isolation in Whites, Hispanics, and others, in that higher population density was associated with greater social isolation.
In any case it's much more complex than "many people = no one feels alone"
Also if you compare the "suicide by county" and "distance to nearest metro area" map there is a very nice overlap:
https://en.wikipedia.org/wiki/Suicide_in_the_United_States#/...
https://www.washingtonpost.com/blogs/wonkblog/files/2018/02/...
I'd say that cities can feel extremely lonely, because you can see all these people all around you but you can't connect with any of them so you kind of feel disconnected or unwanted which heightens the feeling of loneliness. Wheres if you are in a rural location, you might be lonely for lack of people but feel that if you were to find some people that you would get on with them well. Tying this back to the original point, I think if you can take advantage of the huge variety of opportunities the city offers you can easily overcome "city loneliness" whereas "rural loneliness" is much harder to overcome - if you don't get on with the small set of people nearby or don't enjoy any of the small hobby groups available, you're shit out of luck in terms of social interaction and will have to either move, hope someone new moves nearby, attempt to start your own hobby club or get used to your own company.
It has nothing to do with isolation, it has to to how living in a place that does not match our genetics effects us as biologically animals.
This effect is revealing the fact that people ho were genetically adapted to live ate low altitudes should not live at high altitudes.
This may or may not be fair, I don't know, but from my experience, if I'm to theorize a generalization in conjunction with this study:
Poor education. Lack of steady jobs. Low ambition. They consider themselves self-reliant people even if they take government subsidies. Don't need to work much to maintain their lifestyle. Would prefer to get a higher hourly rate, not to extrapolate to have a nice income, but to be able to work like 20% of the year, be paid in cash and also take government benefits. Which is likely also driven by the lack of steady jobs that provide healthcare to be fair. Idle time and lack of structure in their lives leading to higher drug and alcohol usage. Financial and health stress. Leading to higher suicide rates.
Study mentions altitude itself and hypoxia and controlling for income. But one could have the same income in a lower altitude location and have MUCH better access to healthcare, quality of healthcare, and steadier/structured employment than the higher altitude people that take their life.
As with most things, I think it's a combination of factors. And the altitude itself seems to be one of them. Not only from the study's stated hypoxia, but it's a lot harder to work at altitude just like it is in the desert with the heat. When people don't have steady jobs and schedules, they have idle time, and along with other pressures and stress, bad things happen.