When you visit a mother to learn about her child’s suicide, expect to stay awhile. Expect to be asked if you want to visit his room. Or flip through his book of baby pictures. Or see his soccer trophy, which you notice looks identical to your son’s soccer trophy.

“She starts crying, and you start crying,” said University of Utah psychiatrist Doug Gray, recalling his interviews with families whose children have died by suicide.

The conversations were part of Gray’s research into why the number of Utah youths dying by suicide was increasing in the late 1990s. He and other researchers created psychological autopsies for 49 teenagers and young adults, asking relatives, friends and others about the adolescents’ lives and what may have stopped them from getting help.

The project led to successful experiments that improved the mental health of boys at risk in 3rd District Court and are still seen by experts as a visionary approach to preventing youth suicides. But when a federal grant paying for the program expired, Utah abandoned it.

Twenty years later, suicide is the leading cause of death for Utah youths ages 10 to 17. The state’s suicide rate for all ages is more than 60 percent above the national average. The state needs a better approach to prevention.

To help design it, a new researcher will soon begin interviews for hundreds of new psychological autopsies.

Michael Staley, a 33-year-old sociologist hired last year by the Utah Office of the Medical Examiner, expects to spend years trying to answer complex questions: Exactly how at risk are LGBTQ Utahns? What roles do religion and technology play? And why does Utah, like other Intermountain West states, have such a high suicide rate?

(Trent Nelson | The Salt Lake Tribune) Sociologist Michael Staley has been hired to conduct psychological autopsies and other research on suicide in Utah. He'll talk to relatives and friends of those who have died in an effort to understand the state's rising rates and to design prevention programs. This position in the Utah Medical Examiner's office may be unique in the country.

In coming days, Staley will start contacting families, friends and others who knew each Utah youth who died recently by suicide, dating back to September 2016. He will comb through police, court, medical and education records, hoping to discover similarities.

His first priority will be investigating a recent series of youth suicides in southwest Salt Lake County — five of them Herriman High School students.

Staley sees his challenge as similar to the work of AIDS researcher William Darrow, who famously used interviews — “classic shoe-leather epidemiology” — in the early 1980s to figure out why gay men in Los Angeles were dying.

“You’re just trying to gather this wealth of information so you can start connecting dots, and drawing lines, and developing trends based on what we find out,” Staley said, “rather than what we ask.”

An early success

As a psychiatrist in his 30s, Gray worked at Primary Children’s Medical Center in Salt Lake City in the 1990s, assigned to review the assessments of kids who had suicidal thoughts.

The Utah Department of Health, which had obtained a grant for prevention, asked for Gray’s help. Officials wanted to know how to spend it to save the most lives.

Gray had no idea. He called suicide experts around the country for advice. They were surprisingly eager to talk, he said, glad that a young researcher from Utah was intrigued by such a bleak subject. “They’re the loneliest guys in town,” he said, “because you can’t go to a cocktail party on a Friday night and talk about suicide.”

(Al Hartmann | The Salt Lake Tribune) Doug Gray, a University of Utah psychiatrist and suicidologist.

But they all had the same disheartening message: None of the prevention programs seemed to work. They were unsure if programs were even being directed at the most vulnerable people. “What we really need,” the experts told Gray, “is more research.”

So, Gray said, several researchers from the U. and the health department used the federal money to launch what became known as the Utah Youth Suicide Study.

Their psychological autopsies of 13- to 21-year-olds who had died by suicide in Utah between 1996 and 1998 revealed several trends.

  • For four of the eight girls and young women, and for 41 percent of the boys and young men, families couldn’t suggest a single friend to interview.
  • Family and friends reported many of the young people had multiple angry outbursts before their deaths, which researchers noted may be a warning sign more common than sadness.
  • Many were likely stressed from problems in a romantic relationship.
  • A majority had received mental health services at some point. But the researchers also found that the youths often expressed embarrassment about seeking treatment, or figured it wouldn’t help.

Perhaps the most important finding: Sixty-three percent had been in contact with juvenile court. This meant the juvenile justice system might be the ideal place to find suicidal youths and treat them.

So that’s what the researchers tried. A pilot study gave intensive psychiatric treatment and home-based behavioral services to 22 boys, ages 13 to 16, in 3rd District Juvenile Court. A similar group of boys got no extra help.

After a year, the researchers found that the boys who received the treatment had racked up fewer repeat offenses. Their mental health scores improved dramatically. Gray said he was shocked to learn the experiment had even saved the state money, because the treated boys were winding up back in jail less often.

Anyone experiencing suicidal thoughts is asked to call the 24-Hour National Suicide Prevention Hotline, 1-800-273-TALK (8255). Utah also has crisis lines statewide, and the SafeUT app offers immediate crisis intervention services for youths and a confidential tip program.

In 2006, Utah acquired a three-year federal grant worth more than $1 million to offer the same enhanced mental health services to more boys.

Again, they got better: Three-quarters of those who stayed in treatment “became less suicidal over time,” according to a paper, written by Gray and several others, in the journal Psychiatric Services.

Jane Pearson, a suicide research expert at the National Institute of Mental Health in Maryland, said Gray’s research showed other states how to successfully find and treat suicidal kids.

But by 2009, the federal grant money had run out. As the economic downturn took hold, the state decided it would not spend its own money to keep the program going.

The number of youth suicides in Utah began climbing — from 10 in 2007, to 21 in 2010, to 31 by 2013. The preliminary count for 2017 was 42.

‘We didn’t see it as a tidal wave’

In the early 2000s, Utah’s medical examiner noticed a different public health crisis unfolding: Annual prescription opioid deaths had grown from dozens to hundreds in just three years.

Todd Grey’s observation spurred state and federal health researchers to launch a 2008 project similar to the youth suicide study. Over a year, they interviewed family members and friends of about 250 Utahns who died from opioids.

Like Doug Gray’s team, they found common characteristics for people most at risk: being unemployed, dealing with chronic pain and facing mental health or substance abuse problems.

(Rick Egan | The Salt Lake Tribune) Todd Grey, former Utah chief medical examiner, at a court hearing in 2016.

The discovery of those risk factors didn’t lead to targeted prevention programs. But around the same time, the state unveiled new opioid prescription guidelines for doctors and funded a public awareness campaign called Use Only as Directed.

Grey said those and other state efforts appeared to work, making doctors and the public more aware of the danger of prescribing and consuming opioids. The number of overdose deaths dropped by more than 27 percent over three years, before rising again after funding ran out.

Meanwhile, the number of suicide deaths continued to climb — but it would be years before Utah began committing state tax dollars to similar prevention efforts.

Grey, who is now retired, explained recently that his office knew Utah had for years faced a suicide rate higher than the average, “but we didn’t know why, and we didn’t see it as a tidal wave that suddenly hit us.”

Utah had long limited the Department of Health’s suicide prevention efforts to what could be covered with federal grants. The money allocated for Staley’s position is the only state funding provided to the department for suicide prevention, spokesman Tom Hudachko said.

When lawmakers began to fund new strategies, they didn’t resume Gray’s approach.

Instead, they have added coordinators at the state Board of Education and Department of Human Services to oversee prevention and awareness efforts in communities and schools. They’ve created $500 grants for peer-to-peer outreach in schools, released the SafeUT mobile application to help youths communicate with crisis counselors, and recently agreed to pay for more crisis response teams based at the U. and more staff to answer the state’s crisis hotlines.

Today, courts screen youths for mental health needs and get help for those in crisis, although the system can’t provide all kids with care, said Dawn Marie Rubio, the state’s juvenile court administrator.

Still, a Centers for Disease Control and Prevention study released in November said the state could be doing significantly more.

The total number of Utah suicides of all ages last year surpassed 650, a new record high after several years of them.

‘We need … to learn more’

Staley came to Utah four years ago for a different research project: studying sexually transmitted diseases among gay men in a predominantly Mormon state.

A sociology graduate student at the University of New Hampshire, he quickly realized many of the men he was interviewing were struggling with their mental health. Sometimes, they would later reach out to him for help; some told him they wanted to die. He took several to a hospital, and resolved to get more mental health training.

“They’d be fine,” Staley recalled. “They’d come out of the closet, they’d be happy that they came out of the closet. And then, they’d start to experience subtle rejection in their coming-out process — being gay, being Mormon, trying to make these two identities mesh.”

The Church of Jesus Christ of Latter-day Saints mandates celibacy for its gay members. A policy unveiled in November 2015 declares same-sex LDS couples “apostates” and bars their children from Mormon rituals until they are 18 or older.

When the Utah suicide research position came open last summer, Staley was immediately intrigued. He’d long been interested in the factors behind suicide, he said, after losing several friends at his Montana high school. And his recent research had given him practical training for the role.

For each youth who recently died by suicide, Staley hopes to talk with at least four people. In future years, he said, the research will examine additional age groups, LGBTQ people and American Indians.

Staley and three graduate students will be studying a new generation and new factors, such as social media and cyberbullying. While the state explores ways to help youths who are at risk now, Gray said Staley’s research is important to understanding what influences Utah’s high rates of suicide — sorting through possibilities such as the opioid crisis, the rise in binge drinking and cyberbullying, the state’s high altitude and high gun ownership rates.

“We need to continue to learn more about suicide,” Gray said “... and we need to continue to adjust our programming.”

Gray had expected the questionnaires used for the Utah Youth Suicide Study to take about 90 minutes, but found that most families wanted to talk for three or four hours. Some research assistants burned out within days, he recalled. For others, the work caused a lingering depression.

Gray said he sometimes had researchers take a break from interviews so they could recover.

“The only men and women standing are people who are happy almost all the time,” the psychiatrist said of suicide researchers. “And they still get sad — they just kind of bounce back.”

So how will Staley handle this work, for years on end?

He said he tries to compartmentalize his job from his home life. He strives to feel the emotion of the person he is interviewing, while not allowing himself to “fully fathom their pain.” And it helps, he said, that his general outlook on life is hopeful.

‘The more we know … the better’

As part of his job, Staley calls families within hours of a suicide to introduce himself and offer to connect them to support groups and resources. That has allowed groups like the American Foundation for Suicide Prevention to reach survivors sooner, said Taryn Hiatt, the group’s regional director.

“We know if we can get to survivors quickly and help support them, we can help prevent them from struggling, or even more suicides from happening,” she said.

Utah mothers Shari Elliott and Shelle Crookston say they would have appreciated such a call. Elliott lost her son, Avery Kertamus, to suicide in 2013, and Crookston’s son, Jake, died by suicide a year later. Both boys were 15.

(Steve Griffin | The Salt Lake Tribune) Shari Elliott holds a photo of herself with her son, Avery Kertamus, in her office in South Jordan. The 15-year-old died by suicide in 2013.

Avery was preparing to enter high school in South Jordan. He seemed depressed in the days before his death, and Elliott had asked what he needed, if he wanted to talk with her or a therapist. He’d shrugged his shoulders, she explained, and said he was fine.

“We thought he was just being a normal moody teenage boy,” she said. She has never learned what might have contributed to his death. “We have no information,” she said. “We don’t know what the catalyst was for it.”

Crookston’s military family had lived all over the country, and shortly before Jake’s death, they moved from St. George to Colorado. Jake enjoyed mixed martial arts and parkour. He didn’t have many friends, but it didn’t seem like he was bullied, said his mother, who now lives in Sandy.

“It felt like I lost my best friend and my child,” Crookston said. “It still doesn’t seem real.”

(Rick Egan | The Salt Lake Tribune) Shelle Crookston's 15-year-old son, Jake, died by suicide four years ago.

Both said the right prevention program might have identified their sons as being at risk and saved their lives, and they hope families choose to share their memories with Staley.

“The more we know, the more we can educate people, the more we can know how to help the youth, the better,” Elliott said. “Until we can comfortably talk about it, it’s going to be very difficult to make headway.”

This week, Staley plans to begin interviewing parents and friends of Herriman-area youths who died recently. He will then reach out to families around the state who have lost children in the past two years.

“I couldn’t come and do this job unless I thought I was actually going to produce some kind of difference,” Staley said. “But I think we’re set up to make a big impact. And we need the Legislature at the table. We need parents, communities. This is an all-hands-on-deck effort.”