- Suicide is no one's favorite topic to talk about.

But in Wyoming, it's important that we do because our state has one of the highest suicide rates per capita in the nation.

That's been true for most of the 21st century.

Today's guest, Stefan Johansson, is the Director of the Wyoming Department of Health.

His job is to help spearhead efforts to reverse that trend statewide.

I'm Steve Peck of Wyoming, PBS.

This is "Wyoming Chronicle."

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- Stefan Johansson of the Wyoming Department of Health.

Welcome to "Wyoming Chronicle."

We're here today in Casper, where you've recently addressed a statewide symposium on the large general heading topic of suicide in Wyoming.

In recent years, it's become more of a focal point in public health, public policy than it had been prior.

And that's because our statistics on suicide over that period of time have not been so great, have they?

- Steve, no, they haven't.

And it's good to be with you on an important topic.

You had mentioned Wyoming statistics, which going back to the year 2000, and many Mountain West states are very similar, we have seen this linear trend of our suicide rate per capita just going up and up and up.

And folks have recognized that over the years and, unfortunately, over the decades that we do have a problem.

And so as you mentioned in the last couple of years, I think it has become a more of a focal point.

And Governor Gordon has certainly prioritized it and really kicked that down to us at the agency level to implement new things.

Couple of those new things, if I may, that are relatively new.

Wyoming now has a 24-7, Wyoming-based suicide lifeline, what we call the 988 system.

And that's really important for a state like this that's so large in geography, so small in population, that local tacit knowledge of what's available in Wyoming is very important when dealing with folks in crisis to be able to connect them to appropriate resources.

That Lifeline has been up and running for about two years.

And the metrics that I see from our two call centers that are essentially comprise that Wyoming lifeline are very good.

Our speed to answer is incredible compared to the national lifeline.

We're talking seconds, not even minutes.

Around 90% or more over the last two years of calls that come into that lifeline are answered by the Wyoming Lifeline call centers.

- And that's a recent innovation.

A recent development, correct?

- It is.

That's very recent.

And again, we're talking about the speed and the efficiency with which we to help people who make that decision to reach out for help.

And I think we're moving in that direction.

In addition, just very recently in the past couple of months, text and chat functionality as well as geolocation that's not dependent on your area code, has now been incorporated into the lifeline, which is very important.

And so, you know, progress like that has been made, and we want to continue supporting and sustaining those efforts.

A lot of people gathering today for the Suicide Prevention Symposium that my department is putting on.

This actually comes after yesterday's Mental Health Summit that Governor Gordon put on, which was also a very full room of many different types of people from all over Wyoming, community members, providers, practitioners, health policy people, local government, county government, law enforcement.

And I think with both of these events, it shows that suicide prevention and behavioral health in general have become major important topics for the state.

And they're daunting issues.

Our challenges with suicide are suicide rate in Wyoming, which has historically been very high, are tough issues to talk about and tough issues to try to address and solve.

But on the optimistic side, seeing rooms that are this full, that it's not just state government employees, it's folks from all walks of life and all types of professions that have recognized the problem that are coming together to discuss-- - That's what it's gonna take, right?

- The solutions at the state level, solutions at the county level, local level, and maybe most importantly at the community level.

And so this event I think is an opportunity for folks to come together and learn from each other.

We'll have experts that will speak both from my department and from national organizations.

And it's good for Wyoming community members to learn from that.

But also we learn from them.

A lot of action going on.

Regardless of what community you go to, these-- - You mean you state government guys don't have all the ideas?

- We don't have all the answers, and government's not the solution to all the problems.

And I think we hold that sentiment very dear in Wyoming.

And I believe in that.

We do good work, and we want to know what work we can support.

But certainly the state government's role is not always the solution to problems like this.

- What is it in, say, the 21st century in Wyoming and neighboring states also that study analysis contemplation has shown to be behind this higher rate of suicide?

How much do we know about that?

- It's a very good question.

And as Director of the State Department of Health, I desperately wish I had good answers.

Steve, as you know, I claim to know a lot about complicated systems because that's what the Department of Health is.

Medicaid, behavioral health, senior services, public health, we manage a lot.

Direct care facilities.

The world is complicated.

And so I often have good answers I don't hear because there's a lot of speculation of why places like Wyoming, or Mountain West States, or other areas are higher than national averages.

There's a few things that I think are really important to mention as as possible contributors to those rates.

We are rural and frontier.

And what I mean by that is there's a lot of distance between communities and sometimes between people and provision of service or assistance.

That's just endemic to Wyoming.

It's our geography.

- That's not gonna change.

- It's the state that we live in.

But scaling services, especially specialty services is a challenge.

So it causes us to focus on how do we share those resources between communities.

The lifeline's a good example.

Connecting to community mental health resources that might be in the next town or the next county because we can't have every service scaled in every community.

So our rural and frontier nature, I think play into it.

Perhaps a cultural element where, and this isn't unique to Wyoming, but really a national issue of asking for help, being okay, and also knowing that help is available.

That's what we are trying to do with symposium like this, the Governor's Mental Health Summit, is make folks aware that even though services and infrastructure might not be perfect or ideal in certain people's eyes, it is there.

It is there to a certain degree, and we have to do a good job making people aware of that.

It's also it important to note that, you know, behavioral health has taken on a different tone and tenor in terms of how we talk about it.

And that's evolved a lot, especially over the past five or 10 years, as I mentioned, with the cultural issues and stigma around seeking help and addressing your own mental health.

That is also changing.

And I think the awareness and comfort level of being able to talk about these things at the policy level, at the government level and at the individual and community level is really important.

- Isn't that interesting?

I know you're not a psychiatrist, psychologist or physician, any of those things.

You're administering a big department here, but isn't it interesting that when I've got a pain in my shoulder, or I'm not feeling well, or I'm sniffling, I know that something's wrong, but with mental health issues, the people don't always realize that there's something wrong.

- I think that's true, and I think the awareness that physical health and mental health are intertwined and connected, they're not separate and distinct, is something that is growing in its awareness.

And I think we see that more not only on the provider side or the medical or clinical side, but you see that in how people are talking about their own mental health or their community's mental health as well.

Doing what we can at the state level through the programs and funding that we have to make sure that we're targeting the right populations, that our services are available as much as they can be when folks need them is really one of the pillars of the work that's been going on for the past couple of years.

And Steve, there's a balance between what the state's role is in taking care of the most vulnerable and the most in need because most of Department of Health programs and services, for example, do target the most vulnerable.

When you look at our Medicaid program, our home and community-based services for the disabled, our state facilities that handle acute psychiatric individuals, intellectually disabled individuals, we are often in this safety net role.

And behavioral health is no different where the state and certainly this administration and my department, we want to ensure that we are at a baseline providing that safety net level of care with behavioral health services for the populations that we know will end up in the judicial system or in our state facilities.

But also balance that with, we know there's population health efforts that we have to have, which you're referring to, to address our broader discussions about mental health and make sure that communities are engaging in this issue and understanding where the state's role is and where it might not be as much.

And that's where these full rooms that you see today, the symposium or the governor's Mental Health Summit, give me a lot of optimism that in Wyoming we are at our best when we leverage local and tacit knowledge.

And often the solution to some of these issues are best when they're local and not driven or prescribed by the state.

So where we can support, sustain or make increase awareness of these things, that's what these forums are really all about.

- Well, it cuts across a lot of other state agencies as well.

I mean, some people would.

when you read about and listen to presentations like we're hearing today, it's a law enforcement issue in some cases.

Courts are involved.

The education system is involved.

It can be a substance abuse issue, alcohol issues.

There's a firearms element to it in some cases.

It's a big job, and your job got bigger in the past few years because it's a priority of the governor.

The data show that it's a priority in Wyoming.

It needs to be.

How are you handling it all?

- Well, I think it's for good reason that the job becomes bigger.

- Yeah.

- Because it's such an important issue.

And building on what you said, I've been saying for a number of years, having gotten into this behavioral health landscape 10, 11 years ago, there's not really an area of health human services, social services that involve so many cooks in the kitchen as behavioral health.

When you think of when someone in a community is in crisis, it often will involve law enforcement at first.

There's a crisis called.

- Sure.

- And law enforcement responds or maybe a presentation in an emergency room at a local hospital, a critical access hospital.

And in a behavioral health crisis at its most extreme, then county governments, county attorneys, law enforcement with the sheriff's office, state programs, state funding through Department of Health, Department of family Services, et cetera, are all part of this system that in pockets have various components of either ownership or programming.

And what again gives me optimism is over the past couple of years under Governor Gordon's leadership, we have started working a lot smarter instead of harder.

And so the breaking down barriers between these agencies and looking at these populations, truly as shared, whether you are on a Department of Health program or not, or a Department of Family Services program or not, but looking at the person in the crisis itself is how can state government, county government, local government support that has started breaking down a lot of those barriers.

In addition, I've been here for 11 years, and I have never seen the collaboration between branches of government, executive, legislative, and judicial, where we with Chief Justice Fox's leadership have partnered a lot to look at new innovative ways that we can break this cycle of judicial involvement for folks in behavioral health crisis or with behavioral health needs, launching pilot projects to look at diverting folks out of the legal system and caring for them more appropriately.

- She mentioned that to us in an interview kind of like this one.

And echoing your language a little bit, she said, "I realize, and what I'm asking the judges to realize right away is when people come before you in court, very often, that's a person who is in crisis in some way."

- Right.

- And it goes from there.

It's not an issue, is it, where anybody can say, well, it's not my problem, I can't be concerned about that.

- Right.

- Because at least that's the approach that's being taken now, is everybody's gotta be concerned about it because you don't know where it starts.

- And that same phenomenon is replicated locally.

So those entities that I mentioned, you also look at what that means for, let's say the town of Casper here where the hospital, their emergency room, local behavioral health provider are all part of or own a little bit of a piece of this trajectory that someone might be on.

And seeing that as a system as opposed to pockets that you might encounter along the way has been really informative for I think a policy approach that the legislature can take of establishing not only what we're trying to react to, where we see problems, where we see, you know, high rates or large amounts of people going through the legal system, whatever the case may be.

Having a shared understanding of those problems and then really doing the difficult work of analyzing and addressing what's the role of state government here and what isn't the role?

And that's been very productive over the past couple of years.

And having some clarity around what can the state do to bolster these systems and support them, and then what will we be needing to rely on communities, localities, counties, et cetera.

And that's developed a lot of really unique partnerships.

I've talked more with law enforcement and sheriff's offices in the past couple of years than I did in my first seven years here.

And they encounter this issue on a daily basis in a very unique way where they have folks with behavioral health needs in their jails.

And that expertise isn't always available in jails.

So how do we partner, not let administrative barriers get in the way or bureaucratic barriers get in the way, but use the funding, and the supports, and the programs that we already have to be targeted in a smarter way towards their populations, which ultimately we will share.

And that realization and that a little bit of change in the culture between government entities is exciting.

- Yeah, people are interested sometimes astonished to find out, I guess, government private partnership in something can be incredibly powerful and effective.

If either side can just get comfortable with that idea, then you can get a lot done.

- It's absolutely true.

And something folks don't always realize about the Department of Health because we're, you know, the big gorilla in the room, the big agency with a $2 billion budget, over 90% of the Department of Health budget goes out to communities in the form of payments, reimbursements to providers, to organizations, et cetera, where a little less than 10% supports staffing, and, you know, those types of costs in the agency.

Of that 10%, most of those staffing costs are out in our five direct care facilities that are in Wyoming communities or our field offices like public health nursing.

And so that's a little bit inverted compared to most large organizations.

So to your point, precisely, what the Department of Health does a lot is to support communities, support provider organizations in delivering these services, which is really that public-private, public-nonprofit partnership, as opposed to the state dictating and directing the exact way that services are delivered.

- Sure.

- We want those as much as we can.

We want services and solutions to problems like suicide, suicide prevention, behavioral health to be as local as possible.

- Public health nurse is a great example of it.

That's a person who is a public employee.

You see public health nurses in every county in Wyoming, but usually when that public health nurse gets involved in something, he or she is dealing with the local hospital-- - Right.

- The local physician, the local church sometimes, the local school sometimes.

And so that's the connection that people can find through her, through him to your department.

- Absolutely.

Thinking back to this relatively new suicide lifeline, that was a process, let's put it that way, to get that through the legislature to be established.

Some of it had to do with, is this our job?

Is this function already being provided elsewhere?

How's it gonna be paid for?

How long is it gonna be paid for?

I think the statistics show, and you mentioned this earlier, if such a telephone hotline exists, it does get used.

Where do you feel it stands now in terms of its security in Wyoming government going forward?

We're coming up on a new legislative session, for example.

Where does it stand?

- It's a good question, and I have to give our legislative partners a lot of credit here because they were early on two years ago asking the right questions.

How can this be sustained?

Call centers in a rural state are tough to manage and tough to to scale because we have a low population.

You have that fixed cost, that infrastructure there, and call volume at times can be low.

So even those operational questions that the legislature was asking, in my view, were absolutely appropriate.

And then ultimately leading to what's the right way to fund this?

Should this be a standard budget line item for the Department of Health?

And over the past two sessions, the legislature has funded what the annual costs for the lifeline are.

So it is in our standard budget.

And in this past session, because a lot of folks were proposing longer term sustainable financing through trust fund mechanisms, et cetera.

And that account, that trust fund, was created in the last session.

The legislature through the budget directed the state auditor to deposit $10 million into that trust fund.

So all of that is to say for the time being for the foreseeable future here, we have the resources we need to operate those, the suicide 988 lifeline.

How that has worked is we have two call centers, which I think has worked pretty well.

So we have two contracts in the Department of Health for a call center in Casper and a call center in Grable.

And as I mentioned before, the data, the operational metrics, they have looked good the past two years.

It's still tough to staff as many things in health and human services are, but what I'm seeing in the data, in our speed to answer and customer service metrics and the accessibility and availability is good and promising.

And so I don't think we'll run into financial issues with the lifeline in the short term.

- Yeah, and, of course, if the data prove that it's effective, working, useful, valuable, helpful, that would be a good argument for continuing stable funding through the future.

- I think so, and I think more important than just the call centers and their existence is what they do.

So obviously, having someone in Wyoming answer a crisis call was a priority for the legislature, a priority for the governor in creating these lifeline programs, these 988 programs.

But I think more important, and kind of the next step, the vision for them is making sure that in all of the efforts that are going on to improve, sustain, and make more efficient our behavioral health services in Wyoming, that folks who call a crisis line will get connected, get warmly handed off to the next step, which is you may need some assistance, some help, some counseling, some medication, et cetera.

And we want to make sure that our lifelines are equipped with who do you call in those situations, who do you refer to?

And I'm proud of the work that's being done to bolster that.

- I've always viewed it sort of like the brakes in your car.

You might be driving 200 miles out on the highway with not much to slow you down, but when you need it, you gotta have that break work every time.

- Yeah.

- And the same with answering this telephone call.

How do we judge, evaluate, and define success in suicide prevention in Wyoming?

What do you think?

- It's a really good question and I think that the general answer, the oversimplified answer is we wanna see a reduction in the number of suicides and we wanna see the reduction in the suicide rate.

Now, there's a lot that comes with that and underneath that, where certainly on the youth side, there's a lot of work that's done at the local level, the education level to target the problem of youth suicide and youth suicidal ideation.

The, you know, anxiety that's existing in our young population, trying to address that is more than just seeing a reduction in the number of observed suicides.

But we certainly wanna see that rate come down.

And one way that we're looking at that, Steve, is we typically, at the national level and at the state level, you look at these rates per 100,000 and you can look at it on a statewide basis or specific to a county.

And as you can imagine, in Wyoming, it can get very difficult because our population is so low.

So you have these big noisy jumps from month to month, from year to year, and if you just chased those noisy jumps, you'd either be over complimenting yourself and patting yourself on the back on this great reduction or, you know, really panicking because you had a 200% increase, which was from two to six.

- And some of this data is three years old by the time you can really begin to trust it.

It's adding to the complication - Somewhat.

We have good vital statistics, vital records data in the Department of Health that we really work across the Department of Health to make sure that we're all singing from the same sheet of music, but also we have to come up with somewhat innovative statistical techniques and modeling to look at this data because our population is so low, and we don't want to chase all of this noise.

Accordingly, between my office and the Director's Office, the Public Health Division, the Behavioral Health Division, and the Vital Records Office that we oversee, we've come together in the last two years to just try to pioneer some new statistical techniques and model going back 20, 25 years with all of the data that we have, try to model some of these counterfactuals, either by coincidence or by efforts, programs, et cetera.

What would have happened?

What would a model predict our rate would've looked like?

And the reason I mentioned that is just in the past one to two years, by looking a little bit more rigorously at these data, we have started to detect for the first time in over 20 years, a potential flattening of our suicide rate in Wyoming, which is really welcomed news.

Can I sit here and tell you it's all because of our behavioral health efforts, and our programs, and the lifeline?

No, we can't say that definitively, but it stands to reason, and it's intuitive that with the focus that's been put on this issue, suicide in particular, that this flattening that we're starting to observe very early on, so I don't want to over promise, but very early on, that there likely is some effectiveness of some of the things that the state, the counties, and the local governments, and communities have implemented, like the 988 lifeline, like some of the prevention efforts and community coalitions that the Department of Health helps support, but are really driven at the local level, focus on behavioral health, and mental health, and forums, and a culture, that it's okay to discuss it, and discuss it very bluntly, and disagree on solutions.

I think there's room for optimism here because as I mentioned since since 2020, over 20 years ago, our suicide rate in Wyoming has just been on a linear increase, which had been so concerning.

This doesn't mean the work's done, but I think there's likely some effectiveness of the work that has been put into place.

- There's work being done.

- There's work being done.

Good way to put it.

That give gives me room to believe that we should continue the good work and do more.

- What you're trying to do, I think, kind of being a facilitator coming at this target from lots of different angles because the objective, what we're talking about is saving lives.

- Something I tell our Department of Health new employees every month when I get the pleasure of onboarding them to the agency, that when you join the Department of Health, and the reason we take our work so seriously is if we don't do a good job, it can literally mean the difference between life and death for the folks that we serve.

And we don't say that to scare people or be daunting, but it's really motivating and rewarding to know how important and critical the work is.

I would extend that same theme out to folks who work on issues like this in our communities, in our provider systems, in our local governments and county governments, that we don't have all of the answers, and we can't diagnose the problem precisely when it comes to behavioral health and suicide.

But it is very rewarding to know that the work is that meaningful, that it's life and death for people.

And I think you see that level of seriousness and also that pride growing in Wyoming, which is nice to see.

- Yeah, Stefan Johansson is the Director of the Wyoming Department of Health.

Congratulations on this effort that you're helping to lead, and thanks for being with us on "Wyoming Chronicle."

- Appreciate it, Steve.

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