The Washington County animal shelter is not often the first line of defense against suicide. But over the span of three months, shelter staff intervened with seven people who planned to kill themselves.
Most people who are considering suicide will say yes if asked if they plan to commit suicide. The problem is knowing when to ask the question.
An unusual collaboration between the Washington County public health department and the medical examiner’s office has figured out a simple way to do that. It appears to be paying off.
Kimberly Repp, an epidemiologist, has earned national praise for a form she developed that death investigators fill out when they determine the cause of a suspicious death. The information provides more recent data about suicides in Washington County than state or federal reporting systems. The database is then used to identify trends that can strengthen Washington County’s suicide prevention services.
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For instance, several death investigators in one month wrote that the subject gave up a pet to the shelter before dying.
Repp took that information to the animal shelter staff, volunteers and veterinarians, who agreed to be trained in identifying people who might want to hurt themselves and how to intervene.
Her model takes about two minutes to collect the data, and officials say it is saving lives.
A SEARCH FOR BETTER DATA
Five years ago, Repp was tasked with the annual statewide survey of health needs by each county.
Through that process, Washington County residents said again and again that suicide was one of their biggest concerns.
So Repp started to look at what she could glean from the state and national data to help suicide prevention efforts in the area. She was stymied.
Oregon is a founding member of the Violent Death Reporting System, a national effort to provide states with information about violent deaths — which include suicides — to help craft health policy and guide law enforcement. But by the time a local public health worker could access that information, it’s about 3 to 4 years old.
Vital statistics in death certificates only told Repp who is most likely to commit suicide, but not why.
Plus, Washington County is not well-represented by state data, because its demographics tend to be superlative. The county has the most diverse population by race and ethnicity, the highest birth rate and the lowest death rate.
Repp needed better data — a surprise in a state with among the highest suicide rates in the country.
A federal report released this summer said that, on average, two people a day die by suicide in Oregon. The rate increased by 17.8 people per 100,000 over the year before.
That puts Oregon with the 16th-highest suicide rate in the country, but the trend is national. All but one state had an increase in suicide deaths, according to the U.S. Centers for Disease Control and Prevention.
The Oregon Health Authority has prioritized suicide prevention, especially among children and young adults.
Public health officials agree that suicide is largely preventable. But Repp wanted to figure out how.
AN UNUSUAL PARTNERSHIP
The answer sat across the hall.
Charles Lovato has been a medicolegal death investigator for 32 years. He joined Washington County’s medical examiner’s office seven years ago.
His job, along with a team of death investigators, is to show up to the scene of any violent or suspicious death and figure out the likely cause of death.
To do so, he examines the body and on-scene evidence, interviews witnesses and tracks down friends and family. He then writes up a report with a narrative of what he thinks happened and submits that to the medical examiner.
Much of that information is scraped into the state and federal databases and then aggregated.
But Lovato’s work often extends beyond what shows up in the report. His job has traditionally been to evaluate all the information he collects in a binary way — is it relevant to the cause of death or not? If not, then it usually doesn’t end up in any of the resulting data sets.
Repp wanted to know what wasn’t in there, so she approached the death investigation team and asked — could she tag along to some crime scenes?
Lovato was surprised that all that information that never makes it into reports could be useful beyond watercooler talk. He knew that much of what he reports is used in state and national trend lines, but he had never worked with public health officials before and didn’t know what could make his data better.
Repp ended up at about 200 crime scenes. She worked with the death investigators for about 16 months to come up with the form. It collects much of the information death investigators already asked about, but makes sure those answers are logged systematically. The state medical examiner signed off on the whole project.
Now, the county has four years of data on whether someone who died of suicide was the perpetrator or victim of domestic violence in the last 30 days before death or was abused as a child; whether that person experienced a crisis of mental, physical, financial or family health in the last two weeks; whether they struggled with legal, school or job problem at the time.
The right bottom corner of the form allows death investigators to write notes or observations that aren’t noted by the series of yes-or-no questions. That’s where the animal shelter trend appeared.
Repp also found that 25 percent of people who killed themselves had an eviction two weeks before their death. So she worked with the Washington County Sheriff’s Office to add the number of a suicide hotline to the eviction paperwork the county is legally required to deliver. In addition, a mental health worker now comes along to serve the paperwork.
The change took one meeting.
“These interventions don’t cost a lot of money, and they work,” Repp said. “We just had the right data to give them.”
SUCCESSES SHOWN SO FAR
Repp’s work has garnered national attention. In October, she won a prestigious award from the National Association of Medical Examiners.
Between the time she walked off the plane and got back to her Aloha office, she had 200 requests from states — North Dakota and Utah — or counties — King in Washington and Humboldt in California — interested in starting their own databases.
But Repp cautions that the form can only be useful if the local medical examiners’ office is committed, because that team is the one that must collect the data.
“It’s kind of a pressure release for us,” investigator Lovato said. “We’re always trying to look for things that you feel like you’re doing that feels a little more community oriented.”
The Multnomah County medical examiner’s office does not use the form, and Oregon’s state medical examiner said through a spokeswoman that she thinks Repp’s plan is great but will leave the decision up to each county whether it wants to incorporate the form into its work.
For those that do, Repp is willing to send a copy of Washington County’s form and database for a local jurisdiction to adapt. Many places have added opioid-related deaths to the data collection because many of the risk factors are the same.
Once it’s utilized, changes also require buy-in. She has reached out to low-budget motel staff in Washington County to ask if they would participate in suicide prevention training, because the data show people often check in to kill themselves there.
Repp said even front desk employees could help prevent a suicide if they will take the time.
“It doesn’t require some big production,” Repp said. “You just have to have the courage to ask the question.”
Because the data is local and collected in real-time, it has also been embraced by Washington County’s suicide prevention council and other groups that can tailor their efforts to the needs of the local population. Many parts of Oregon will see that older white men are a prime demographic, which is true of Washington County as well, but the growing Latino population means that suicide prevention efforts must be culturally specific and in Spanish.
“It works because it’s local,” Repp said. And, because it’s relatively easy once the right people know who to ask. “I ask people all the time. They probably think I’m a weirdo. Which I am.”