Oby Ukadike-Oyer: From the campus of Harvard Medical School, this is ThinkResearch, a podcast devoted to the stories behind clinical research. I'm Oby, your host. ThinkResearch is brought to you by Harvard Catalyst, Harvard University's Clinical and Translational Science Center, and by NCATS, the National Center for Advancing Translational Sciences.

Content warning-- during this episode, we discuss experiences with depression, suicidal ideation, and suicide. We acknowledge this content may be difficult for listeners and encourage you to care for your safety and well-being if you choose to listen to this episode.

Join us as we hear from Dr. Sara Kohlbeck and her interest in focus on understanding suicide from a public health perspective. She is conducting research that focuses on better understanding suicide among disproportionately affected populations, including farmers, veterans, and youth of color, to facilitate the development of appropriate prevention strategies. Dr. Sara Kohlbeck is the director of the Division of Suicide Research and Healing in the Comprehensive Injury Center at the Medical College of Wisconsin. She is also an assistant professor in the Department of Psychiatry and Behavioral Medicine.

Sara Kohlbeck: Hello, my name is Sarah Kohlbeck. I am currently living in Milwaukee, Wisconsin. I'm actually from a small town in Wisconsin-- Two Rivers, Wisconsin-- just about an hour and a half north of Milwaukee. I've spent pretty much my entire life here in Wisconsin minus a few years living in Colorado and a few years living in Texas, and continuing to do my research and my work here in Wisconsin.

My research really focuses on a public health understanding of suicide. I started my career as an educator. My bachelor's degree is actually in Education, and my major was Spanish. Obviously, I did not end up being a Spanish teacher, although it certainly helped with the current work that I'm doing. In terms of what I took away from education and teaching, it was interesting because when I was teaching Spanish back in the early 2000s, I was teaching in Texas in the early 2000s.

One of the interesting things that I learned, I think that was probably my first exposure to inequities that we see in funding for different topics, different subjects, particularly topics and subjects that maybe aren't as central to some of the curriculum as things like math and science and reading, which are obviously very important, but having taught Spanish, which is not one of those core subjects, was really interesting how if the subject wasn't something that was sort of one of those core subjects that really was not funded well. And so that was actually one of the reasons that I got out of teaching.

Then, I ended up getting my master's and my PhD in Public and Community Health. I'm currently working at the Medical College of Wisconsin in Milwaukee. I am an assistant professor of Psychiatry and Behavioral Medicine here at the Medical College of Wisconsin, and I also direct our Division of Suicide Research and Healing in MCW's Comprehensive Injury Center.

What attracted me to the field of public health was, first of all, a focus on prevention and a focus on trying to understand what causes different health issues and what can be done to prevent those health issues from occurring. And I think I was also attracted to the social justice, health equity lens that public health brings to the conversation.

And so I really approach my work in suicide research from that public health perspective versus a clinical perspective. I think a lot of the research and understanding so far in the field of suicide and suicide prevention very much comes from a clinical perspective. And I think that research in the past has sort of pathologized the idea that suicide is a mental health issue that has a cause and therefore has a treatment protocol, and that treatment exists primarily in the health care system.

It's certainly getting better, but when I think about suicide from a public health perspective, what I mean by that is really thinking outside of the individual. Of course, mental health issues play a role in suicide, but we know that other factors influence suicidal behavior that are kind of outside of the individual. I think the field is moving more in the direction of that public health understanding. But when we talk about that public health understanding, we're really thinking about social determinants of health.

So we're thinking about things like housing, access to health care services. We're thinking about really big sort of macro-level factors like structural racism and discrimination. We're thinking about things like interactions with the legal system.

The public health understanding of suicide really broadens and expands upon the more traditional mental health-based understanding of suicide. And I think the fact that we are expanding that understanding really helps to expand the conversation around prevention. Certainly, mental health treatment and medication, those more traditional treatment modalities for suicidal thoughts and behaviors are effective for many people. And also, I think that suicide prevention exists within the realm of policy change.

Really interesting research has been coming out of some states that have, for example, increased their state minimum wage and how that increase in the state minimum wage is associated with reductions in suicide.

Now, we can't tie those together through a causal relationship, but we know that financial strain and stress is an experience that precedes death by suicide among a lot of people. And so if we're able to create environments through policy that are a bit more supportive for folks, that really can, I think, make a major impact when we're talking about suicide and suicidal thoughts.

And so really, that is what I'm talking about when I talk about suicide research from a public health background is really focusing on the policies and systems and environments where people are living and existing and helping to make those environments and those policies and those systems more supportive in terms of suicide and suicide prevention because I do think that's where prevention lies.

In terms of the experiences that have led me to the work that I do now, as I mentioned, I started out my education actually in Education. I was a Spanish teacher for a couple of years and then really left the field of education and was looking for something else, something that would fit a little bit better kind of with my long-term goals. I always loved education. I loved learning, and through the work that I did in my master's and my PhD program, I really discovered my love for research.

I started working and looking at issues related to violence and violence prevention when I was working on my master's at the University of Wisconsin Milwaukee. And it was really through that work that I discovered a passion for better understanding suicide and suicide prevention.

I'm somebody who has lived experience with mental health challenges, and I myself have had experience with suicidal thoughts. And so the research that I do and that I've done I think really leans a bit on that lived experience, and not only about our understanding what is happening in the world as it relates to suicide, but also kind of better understanding of what's happening in our community, better understanding of what's happening with myself. And so my passion for this work comes from within. It comes from the outside as well.

So in my master's program I began studying specifically issues related to suicide among veterans. I have an uncle who served in the Marines for 20 years, was a veteran. And so really felt like this exploring suicide among veterans was something that was of interest to me, for sure.

There is that sense of being strong for others, being there for others. And oftentimes, when folks are sort of transitioning from that time in the service as a service personnel to life as a civilian again, that can be really, really challenging. And again, there's that sort of fracture a little bit, maybe in that sense of identity and sense of self that is partially internal, certainly, but partially culture-based.

I think it's one of the things that's really interesting with the veteran research that we've done is veterans have talked to me about the perceptions that civilians have of them when they're coming out of the service or maybe even when they're still in the service and how sometimes there are sort of negative perceptions or they're feeling negative perceptions from civilians that really, really again impacts that sense of self. And so in the context of veteran suicide, we talk about things like PTSD, and we talk about things like traumatic brain injury. All of those things are very important.

But there are also other sort of cultural factors that can play into suicide among veterans. And I think, again, those are important to consider. That was really what got me started in this space was working on projects related to veteran suicide prevention. When I came to the Medical College of Wisconsin in 2015, I started working as an evaluator on a statewide suicide prevention grant for youth and so was fortunate to be able to of step into a professional job that aligned with my research interests during my master's program.

That work and that interest really has blossomed now into the work that I'm doing currently as a faculty member at the Medical College of Wisconsin. My research now primarily focuses on, again, understanding suicide among groups that are disproportionately affected. When we think about suicide here in Wisconsin specifically, we typically see the rates are highest among middle-aged men, older men, and specifically white men.

My work focuses a bit more on specific groups that are affected at higher rates than others. My dissertation work focused on suicide among farmers in Wisconsin. I did a fully qualitative dissertation that included interviews with Wisconsin farmers to talk about some of the stressors and supports that they face in their daily life.

When I did my dissertation research on farmer suicide, it was pretty interesting to see some of the factors that preceded death by suicide. Now, there has been quite a bit of research in the farmer suicide space internationally. There's been less in the United States. And so when I was going into my dissertation research, I was keeping that global perspective in mind but understanding that our context here in the United States and specifically in the state of Wisconsin, where I did my research, is very different than a lot of other places.

And so when I did my dissertation research with farmer suicide in Wisconsin, I looked at every single farmer suicide death in Wisconsin for an 18-year period. There were several themes that kind of emerged. One that I think is really interesting and is sort of amenable to policy change is access to firearms. We talk a lot about access to lethal means in the context of suicide prevention. About half of the folks who die by suicide use a firearm, but when I looked at the farming population in Wisconsin, that number was closer to 70%.

Having access to firearms is just kind of part of daily life in farming communities. Many farmers that I talked to were hunters. Many recreationally used firearms for different shooting sports. And, of course, with some of the farmers that I talked to, they actually use firearms as sort of a tool of their job to help with pest management, keeping coyotes and things like that off of their property, away from attacking their cattle and their herds, and so really as a tool of the trade. And unfortunately, that reality translates into higher rates of firearm suicide among farmers.

With my farmer research, I also noted of this culture of rugged individualism, really a sense of self-reliance among some of the farmers that have died by suicide. In many of the suicides that I reviewed, we had farmers who were injured or were dealing with chronic pain, a chronic disease that compromised their ability to perform in a way that they had in the past and how that was really one of the contributing factors to their suicide.

That's a culture-level factor that is going to take more to work with than therapy or medication. That's really about culture change. I think that's an important factor to tease out as well. And really that information, I believe, can help us better understand what we can do to prevent suicide from happening in the future.

I'm also continuing to conduct research on veteran suicide. I'm working with a couple of different projects right now that focus on suicide among veterans. We're currently working on a project, my colleagues and I, called Remembering the Lost, where we are talking with family members and loved ones of veterans who died by suicide, again, to better understand what happened in the lives of those veterans before they died to help us develop strategies for prevention.

What we are finding is that many of the veterans who died were engaged in mental health services. Many of them were honorably discharged, but there were a number of stressors that they were facing in their life sort of after they were discharged from the military that contributed to their suicide death. And so trying to, again, tease apart those factors, better understand those factors, and then help to develop and suggest strategies for prevention.

And then, finally, we've been doing some work in our division around suicide among youth of color. Since the pandemic and prior to the pandemic as well, nationally, there were trends identified that demonstrated increasing rates of suicide and suicide behavior among young folks of color-- really, really young folks, age 10 and under in some cases.

This is going back to that public health perspective as it relates to suicide. We are really seeing the impact of things like structural racism and segregation, particularly here in Milwaukee, which is one of the most segregated cities in the state, and the impact on the mental health of young people in the context of that segregation, that institutional racism, and living in communities where there is really, really prevalent community violence, that sense of social discord, and that perceived discrimination, perceived and real, I would say, discrimination.

The minority stress that these young folks are dealing with on a daily basis has a negative impact on the mental health of those young people, which then again can-- certainly doesn't always-- but can contribute to suicidal thoughts and behaviors. These three different demographic groups-- farmers, veterans, and young BIPOC individuals-- very, very different groups of people. But as I think about some of the common themes that I see across those three groups of folks, really, again, I'm reflecting on really the policy systems and environment-level factors that are contributing to suicide.

Taking that public health approach, if we are able to address some of these policy systems and environmental factors, we're not going to be preventing suicide in one person. We're going to be preventing suicide in an entire group of people. I think it's important to push that prevention upstream to affect as many people as we possibly can. I don't necessarily think that it's possible to prevent every single suicide. I think that those of us in the field are doing the absolute best that we can in this space.

And I think that there are a lot of different factors that go into suicide, right? It's not just housing. It's not just a mental health challenge. It's a lot of these things sort of coming together in a person's life. But I think as we start to dismantle and address some of these really harmful systems of power that have been in place for such a long time, we can really do a lot in terms of suicide prevention.

The other thing that I really want to mention that we've been working on as a division is work around support for suicide loss survivors. We know that for every death by suicide, about 135 people are exposed. That includes family members, friends, other loved ones, colleagues, coworkers, neighbors, and so our work is really twofold in that space-- number one, trying to understand what that impact looks like, and number two, providing support to those folks who are affected by suicide loss.

So our division has developed a program. It's called MKE LOSS-- MKE for Milwaukee, LOSS as an acronym for Local Outreach to Suicide Survivors. And what we do is we contact suicide loss survivors in the week or two after their loss to offer support and to offer to help connect them to any resources that they might need. That could be clinical, mental health support. It could be financial support, housing support, support with planning a funeral, whatever that might be. We are here to help kind of with that resource navigation and connection.

And then as part of that work, we are collecting data on grief-related outcomes for those folks. We are really hopeful that our support in our program is helping to mitigate some of the negative effects that we see of these losses. Typically, we see things like prolonged and complicated grief. We see folks who have experienced a loss by suicide having thoughts of suicide themselves. And so we really hope that our program, again, helps to mitigate some of those negative outcomes.

And so we are collecting data right now with our program participants on things like complicated grief and prolonged grief and suicidal thoughts and behaviors. We're also collecting some qualitative data from those folks. And what we have seen sort of preliminarily in the months or so since this program has been off the ground is that we are providing a service that is helpful to folks. Many folks in the wake of a traumatic loss like this really are kind of at a loss for how to find the resources that they need.

And we've heard from our participants that our program, as one participant described it, is almost like magic. They didn't have to really do anything, and we were able to provide the resources that those folks needed without them having to, again, do that outreach themselves in the wake of that loss.

We're also seeing reductions in kind of those symptoms of prolonged grief over time, which is really encouraging as well. So we continue to do this work with these participants and others. We've expanded our outreach to include work with faith communities and funeral homes as a way to refer folks to our program. So we're really excited that this program seems to be taking hold of it and, at least preliminarily, seems to be leading to some positive changes in folks' lives as they're navigating loss from suicide.

And really that is the goal of the research that we do, right? It's to serve our community and help make the lives of folks that either are at risk for suicide or have lost somebody to suicide, to make folks' lives easier and better. We understand that suicide is an issue that is not rooted in the individual. It's rooted in relationships and the community and policies and systems in our society at large. And so really, the goal of our work is to bring understanding to the fact that suicide is not simply a mental health issue. It's a public health issue. It affects individuals, certainly, but it affects communities.

All of us have been touched by suicide at some point in our lives. And so really hoping that folks understand, one, that suicide is a public health issue and, two, we all have the ability to help with suicide prevention. I think one of the things that I've learned from the work that I've done over the past decade or so is that, really, the key to suicide prevention is connection. The better connected that we can be, the more support that we can show each other, the better off that we will be in terms of suicide and suicide prevention.

I think it seems simple, relatively simple, but all of the research that I've done, all of the reading that I've done, all of the talking to research participants that I've done, it really does come back to connection and the importance of connection and that real authentic connection. And I hope that when people look at the research that I do, they understand that.

They understand that you don't need a certain kind of expertise. You don't need specialized training. We can really all provide that connection for one another. We can all reach out and check in on colleagues, loved ones, family members, friends. We can all be that piece of suicide prevention that is so critical.

It's about so much more than mental health. It's more than anxiety and depression. Those things are very important, obviously. It's more than bipolar disorder. Obviously, that's an important piece of the equation in some cases. But it is about the world that we're living in, the context that we're living in. And so yeah, that's what I hope that people understand from our research.

In terms of what is next with our research, we're continuing to expand our work looking at disparities in suicide. We are continuing our research around folks who are bereaved by suicide. One of the things that we have discovered in our work with loss survivors is that there's really not a lot of space currently for grief and loss and healing as they're experienced in non-white communities.

And so we're really interested in working with minoritized populations to better understand how they experience grief from suicide loss and what they need in terms of support to help navigate that grief.

And so we're working with the Hmong community here in Milwaukee County. We're working with the Black community here in Milwaukee County, again, to better understand those grief experiences and to understand what's needed. In many cases, it's not clinical therapy. In many cases, the desire is to rely on more traditional methods of healing. And so how can we work to make those practices a little bit more accessible to folks who need them in the community? And how can we partner with organizations to elevate the work that they're doing to make that support more accessible?

We are continuing to explore these avenues, continuing to explore the different lived experiences of folks who live with suicidal thoughts and behaviors. We know that the experience of suicide is different for every person. How can we tailor our prevention strategies to be relevant to that personal experience for folks?

I think that there is a lot of work to do in the field. And I also think that there is a lot of really innovative, cool work being done, and that gives me a lot of hope for this work in the future. And so I'm excited to see how far we're able to progress in terms of suicide research and suicide prevention.

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