When it came time to explain her father’s death, Taryn Aiken Hiatt insisted on telling the truth.
Terry Aiken had battled depression and anxiety for years. His 22 surgeries left him in grueling physical pain and, at times, out of work.
The Orem, Utah, man didn't get consistent therapy. Like many men in the rugged Mountain West, he kept his health struggles to himself.
In October 2002, he took his own life.
His death launched Hiatt’s career as an advocate – starting with her own family.
“The family wanted to say he had a heart attack,” Hiatt said. “I said, ‘No, no, no, we’re not doing that. We’re going to talk openly about what his experience was, because he was shamed.’”
More than a decade and a half later, leaders and advocates are still working to combat the stigma of mental illness that remains as vast as the majestic Wasatch Range Mountains in this state that values independence and self-reliance. Many in Utah and the Mountain region of the United States don’t seek help they desperately need, and the rural West makes access to care difficult for those who do.
Utah suffered the nation’s highest rate of major depression in 2017, according to researchers at the University of Washington’s Institute for Health Metrics and Evaluation. Mountain West neighbors New Mexico, Idaho, Wyoming, Montana, Arizona and Nevada rank in the top 10.
Seven of the 10 states with the highest suicide rates in 2016 were Mountain West states, according to the Centers for Disease Control and Prevention. Montana had the highest suicide rate, followed by Alaska, Wyoming, New Mexico and Utah.
Kimball Gardner is prevention program director at the National Alliance on Mental Health’s Utah chapter. The Salt Lake City man says many people with depression don’t think they need help. That's particularly concerning in a region with high gun ownership in rural areas with limited access to care.
“We are a culture of pick yourself up by your bootstraps and you can do this alone,” Gardner said. “It’s kind of a cultural thing that we can just tough this out.”
Gardner knows from his own experience that a person cannot hope to get better by ignoring mental health. He was a successful trial lawyer specializing in criminal defense and personal injury law. Others would approach him when they needed help, not vice versa.
But while he had career success, depression and anxiety pushed him into a dark place. He reached out to colleagues for help.
Admitting he had depression was a big relief, he said. He sought care and has developed skills to manage his own well-being.
Now, he shares his experience with others, including men like himself, who might be reluctant to get care.
“It is not unmanly, a failure or laziness,” Gardner said. “It’s a real wonderful thing to send a message to others: Don’t wait. Don’t try to tough it out.”
Rates of depression are rising nationwide. An estimated 6.7 percent of U.S. adults experienced at least one episode of major depression in 2016, according to the National Institutes of Mental Health.
By age group, young adults had the highest rate.
About one in six Americans suffer depression in their lifetime.
The World Health Organization ranks the condition as the top cause of disability worldwide, and a major contributor to burden of disease. People with cancer, diabetes, heart disease, stroke and Parkinson’s disease are more susceptible to depression – and depression can make these diseases worse.
Depression is also costly. In 2015, the economic burden of depression in the United States surpassed $210 billion in direct medical, workplace and other costs.
A person has major depression when she or he feels depressed or experiences a loss of interest or pleasure that lasts at least two weeks. Individuals can have trouble sleeping, eating or concentrating, or experience a lack or energy. Women are more likely than men to suffer depression.
Advocates and researchers say risk factors such as genetics, brain makeup or childhood trauma are complex and not fully understood. They're not certain why depression is on the upswing, particularly among adolescents and young adults.
"We are somewhat more willing to talk about our emotional state," said Dr. Philip Muskin, a professor of psychiatry at New York Presbyterian/Columbia University Medical Center. "That's not true across the board, but I think there is more willingness to admit this and somewhat less stigma than there was 40 or 50 years ago."
Access to care remains a challenge for many.
About 56 percent of adults with mental illness do not get treatment, according to the advocacy group Mental Health America. That's up slightly from 2011, but barriers remain: a lack of insurance or limited coverage, a dearth of mental-health providers, a lack of treatment options.
Researchers at the Washington, Wyoming, Alaska, Montana, Idaho Rural Health Center, based at the University of Washington, reported this year that 47 percent of non-metropolitan counties in the United States lacked a psychologist, and 81 percent lacked a psychiatrist.
The decade-old Mental Health Parity and Addiction Equity Act requires most insurers to cover behavioral health services on par with medical care. And Affordable Care Act insurers are required to cover behavioral health as an essential benefit in individual health plans.
But critics say the parity law is often ignored, or not enforced at the state level. And new Trump administration rules that allow the marketing of less-expensive, bare-bones plans that can exclude benefits such as behavioral health.
Former Rep. Patrick J. Kennedy, D-R.I., has called for more enforcement of the parity law, to guarantee better access and treatment for people with depression, anxiety and other mental illness.
"How can we say we are against stigma when we reinforce stigma by allowing some separate and unequal system of care continue to take place?" Kennedy told USA TODAY.
While many patients lack access to specialty psychiatry care, studies suggest that many also don't get routine mental health screening from their family doctors.
The U.S. Preventive Services Task Force recommends routine screening of adults, and for pregnant and postpartum women, for depression. But from 2005 through 2015, only 1.4 percent of adults were checked, according to one study.
Although screening has gradually increased mid-decade, it's clear most providers still aren't asking patients about depression.
That leaves it up to patients to volunteer the information, and many have no interest in bringing it up with their doctors.
Kevin Berthia kept busy as a child in Oakland, California. His days were occupied with school and sports. To his friends and family, he was a happy child and always quick with a joke.
But when he was alone at night, he felt different.
"I come from the African-American community. Nobody who looked like me, I felt, was up and crying at night," Berthia said. "I didn't hear the words "depression," "mental health," until I was 19."
That's when he was hospitalized and learned that he had mental illness that he didn't want to acknowledge.
Berthia, who was adopted, thought the birth of his daughter would fill a void he had felt since childhood. But his daughter was born premature and hospitalized for nearly seven weeks. As a newborn, she needed a hernia operation.
He blamed himself. In March 2005, he drove to the Golden Gate Bridge. He parked his car at the north end of the iconic structure. He walked to an deck and eased his body over a railing.
California Highway Patrol Officer Kevin Briggs called out to Berthia. The two talked for 92 minutes. Briggs convinced Berthia he needed to be present for his infant daughter's birthday the next month.
The Golden Gate Bridge encounter was captured in a dramatic photograph that was widely published. Still, Berthia refused to acknowledge his mental health with family and friends.
Eight years later, he was invited to speak at an American Foundation for Suicide Prevention dinner in New York. The annual gala raises money and honors those who work in suicide prevention and mental health awareness.
That night, on stage, he spoke openly about his mental health for the first time. He has since become active in the prevention community.
"For eight years, I went on like that day never existed," Berthia said. "I got up there an openly spoke about everything in my life that led up to that day. I felt the weight being lifted off of me."
'I was finally able to tell the secret'
Utah officials are working to address mental health needs both through legislation and administrative action.
The Utah Department of Health and the CDC conducted a study of youth suicides last year. They found that the state’s suicides among youths aged 10 to 17 increased 141 percent from 2011 to 2015. The national rate increased 23.5 percent during the same period. More than one third of the Utah children who died had a mental health diagnosis and nearly one third were depressed.
During his state of the state address in January, Gov. Gary Herbert said the number of youth suicides “horrifies me” and vowed to address the challenge through legislation. The Utah legislature this year passed eight bills to bolster crisis response and fund suicide prevention programs.
The state requires high school students to take life skills classes on mental health and substance abuse, Gardner said.
The Utah Office of Medical Examiner became the nation’s first to create a suicide prevention research coordinator. Michael Staley, a sociologist, uses his skills to interview up to four friends and family members following a loved one’s death. He calls the process a “psychological autopsy.”
Staley says the in-depth interviews provide clues of psychological stressors and mental health challenges in the person’s life.
The office also wants to learn about factors that helped keep the person alive.
“We have two important questions: Why suicide? And why suicide now?” Staley said.
Those are questions for which Hiatt, director of the American Foundation for Suicide Prevention's Utah and Nevada chapters, knows there are no simple answers.
Hiatt, who counsels people and holds prevention workshops, has struggled with her own trauma.
As a child, Hiatt says, she was sexually abused by a neighbor. She felt an overriding guilt that ate away at her. When she was 12 and her parents were going through a divorce, she attempted to take her life.
Two more attempts followed in her teen years before she was admitted to a mental health facility. She stayed for three weeks.
“I was finally able to tell the secret,” Hiatt said. “And just being able to get that out was a huge turning point for me.”
She says the truth allowed her relief and healing. But the path was not easy. She battled addiction with alcohol and drugs.
"It was easier to drink a glass of wine at night than face what I really needed to face," she said.
She has been sober for six years. She still struggles with depression, but she has learned coping skills and self-care. She sees a therapist, does yoga and pilates, takes supplements and attends recovery groups.
A couple of years ago, following a bad breakup, she got rid of a firearm from her home.
Her knowledge about mental health, coping skills and her openness have saved her. She tries to share that message with others.
“I do think increased awareness has more people coming out, seeking help and talking about it,” Hiatt said. “We need to continue it.”