In the U.S. for 2014 -- Suicides: 42,773 -- Murders : 14,249

Thirty-four year-old Emily Rodriguez – a Dover resident – had spent almost half of her life struggling with suicidal thoughts triggered by the traumatic memory of losing her premature child 14 years ago.

“When I lost my son something happened to me. I couldn’t quite be normal again and tried suicide right after that. I took a bunch of pills and ended up in the hospital,” Rodriguez said. “I blocked a lot of stuff out, but I remember that I had to go somewhere – Dover Behavioral Health –and I did, but didn’t want to see therapist. I was going to tough it out.”

The mental health hospital gave her a prescription for an antidepressant, but Rodriguez said she began to overmedicate and ended up with an addiction to pills.

“After that I also began to take illegal drugs, and it wasn’t to try to get high. The drugs made me feel normal,” she said. “I could hold a job, I was functional, but I was numb inside, walking around feeling like a zombie.”

Over time, Rodriguez started abusing alcohol and experiencing extreme mood swings, which caused her first marriage to fall apart.

She began attending a 12-step program, but it was a while before she could cut back on the drugs and some of the alcohol.

Eventually Rodriguez met her second husband, but the trauma of losing her child would return again and again, making it hard to have a normal life.

“I was self-injuring, suicidal – planning on taking my life. I was having a lot of nightmares, flashbacks. I knew I needed help,” she said.

On the internet, searching for possible treatments, she read about Dialectical Behavior Therapy.

The suicide epidemic

A National Center for Health Statistics study released in April showed the number of suicides in the U.S. increased 46.5 percent from 1999 to 2014, the latest year statistics were available. The total climbed from 29,199 in 1999 to 42,773 in 2014. Over the same time the nation’s population grew 14 percent.

Proportion of causes of death, 2014. After accidents, suicide is the second leading cause of mortality between ages 15 and 35. Sources: National Vital Statistics System, National Center for Health Statistics, Centers for Disease Control.

An estimated 14,000 Delaware residents are, like Rodriguez, at risk for suicide, according to the National Institute of Mental Health. These are people living with borderline personality disorder – an underdiagnosed mental illness that is congenital or created by trauma. It causes unstable moods and impairs one’s ability to maintain relationships with other people.

Hundreds more may be at risk for suicide due to other mental illnesses, including bipolar disorder, major depression, schizophrenia and substance abuse.

BPD carries the highest risk for suicidality – a term used by the mental health community to describe an individual’s likelihood of committing suicide.

Dr. Matthew Ditty, founder of the Ebright Collaborative, a Wilmington mental health practice, said many therapists don’t want to treat suicidal individuals or those with borderline personality disorder because they think they’re too difficult.

A licensed clinical social worker, Ditty said every week he turns away at least four to five suicidal men and women seeking DBT– the gold standard treatment in the mental health community for a variety of disorders, including chronic suicidal and self-harming behaviors.

Dr. Matthew Ditty is pictured at his mental health care practice in Wilmington. He said he has a six month waiting list for clients with chronic mental illnesses, including borderline personality disorder. DOLORES M. BERNAL PHOTO

“Turning people away is the most stressful part of my job. It affects how I sleep,” Ditty said. “I want to help them because it’s my life’s work, but there are so many challenges to overcome.”

Ditty is one of a handful mental health providers in Delaware offering comprehensive DBT treatment. He said he has a six-month waiting list. Colleen McGinnis, a psychologist in Middletown, also has more patients seeking DBT treatment than she can handle.

“[I] have a waiting list of eight at the moment,” McGinnis said.

Success story

One reason clients seek the therapy is its high success rate. About 60 to 70 percent of those who complete treatment go on to live normal lives, Ditty said.

According to an NIMH-funded 2007 study of women with borderline personality disorder, DBT therapy reduced suicide attempts by half compared with Cognitive Behavior Therapy, psychodynamic therapy and supportive therapy. The study also showed that DBT reduced emergency room visits and inpatient services.

Clients like Rodriguez learn mindfulness skills – observing body sensations and thoughts at any given moment to remain aware of the intensity of emotions. Other skills show clients how to effectively handle relationships. “Distress tolerance” skills are used when emotions are high or a patient is in crisis.

Rodriguez has been driving twice a week from Dover to Ditty’s practice for her 12-month treatment. She attends both individual therapy sessions and two-hour group classes with about nine others.

“I like the class – in most places you only get individual therapy,” she said. “I’m learning to deal with my emotions and how to use the skills.”

Ditty said progress is measured weekly when clients submit “daily diary cards” used to track their emotional levels.

This “mindfulness bowl” is used at Dialectical Behavior Therapy classes to practice mindfulness skills and help clients be more aware of their emotional state. There are other coping skills that DBT clients also learn to help them in times of emotional crises. DOLORES M. BERNAL PHOTO

The success of DBT has prompted several states, including Pennsylvania, Minnesota, Washington and California, to start pilot programs. They have also begun using DBT in public and private psychiatric hospitals, outpatient facilities, prisons and schools.

But there are major challenges to providing DBT in Delaware, starting with a shortage of providers. Insurance is another challenge, as high deductibles may prevent patients from seeking the treatment, coupled with sometimes inadequate reimbursement rates that providers receive for full treatment.

High demand, few providers

Dialectical Behavior Therapy was developed in 1993 by Dr. Marsha Linehan – a world renowned figure in suicide and borderline personality disorder research.

As she designed it, the provider must offer individual sessions along with group classes where the client learns coping skills. The therapist also offers phone coaching 24 hours a day, seven days a week and must have a consultation team – a group of therapists who support each other.

According to Frann Anderson, director of Alcohol and Drug Treatment Services at the Delaware Division of Substance Abuse and Mental Health, although DBT is known to be effective, it’s really difficult to find out who is doing it right.

“There have been hybrids of DBT in the years after it was developed to treat all sorts of other diagnoses, but it’s very intensive and requires a lot of support for the therapist working with these clients because the population is so difficult,” Anderson said. “So while some therapists have adopted DBT and see it as working best with suicidality – I always have to ask them what that [treatment] looks like because there are so many hybrids now and watered-down versions that are not pure DBT.”

Efforts are underway to make DBT more widely available. Last year, the nonprofit insurer Highmark Delaware gave Children and Families First a $267,000 grant to hire therapists to provide DBT treatment and Cognitive Behavioral Therapy.

The Division of Substance Abuse and Mental Health – a department whose budget this year was $133.2 million, the second highest after education – has used providers like Ditty to help some of the clients under state care struggling with mental health ailments and substance abuse disorders. But aside from that, the state hasn’t created a pilot program.

Ditty said Delaware’s DSAMH could fund a training program like Minnesota does so there can be more therapists offering DBT, but his proposals have faced opposition.

DSAMH Director Michael Barbieri said he doesn’t have any plans for expanding DBT here.

“It’s a great idea and we think the Ebright [Collaborative] is a good entity, but we want to use it selectively and not just say we’re going to start funding DBT therapy and then have everyone doing that this week,” he said. “We want to make sure it’s for the right people and something people can feel comfortable with. It’s an intense intervention which I think it’s good for certain people.”

Deductibles and payment

Mental health treatments for suicide prevention are in high demand, according to Dawn Schatz, a therapist who runs Appoquinimink Counseling on Main Street in Middletown. Not only are therapists like her overwhelmed by the number of patients, she said, but many clients find it hard to pay for treatment.

“More people than ever now have extraordinarily high insurance deductibles to meet before insurance payments will cover the services,” Schatz said, citing deductibles ranging from $2,500 to $5,000. “So the reality is that consumers are paying for their ‘coverage,’ but never receiving the financial benefits … [because] of the tremendous financial barriers to actually receiving the treatment. This, unfortunately, is a very real factor in whether a person starts therapy and how long they will continue.”

Some patients who have Medicare or Medicare may have a hard time finding a provider who accepts that coverage. Ditty, for example, does not have a contract with Medicaid or Medicare. McGinnis doesn’t take Medicare either.

Ditty said he has pushed to meet with representatives from Highmark to renegotiate his contract and get the company to increase reimbursements so he can pay competitive wages to therapists in training. He said he wants Highmark to pay for the 24/7 phone coaching he offers.

For its part, Highmark Delaware issued the following statement, “The model utilized by Dr. Ditty is one of several approaches appropriate for the treatment of borderline personality disorder on an outpatient level of care basis. Highmark Delaware reimburses providers accurately and fairly for the level of care they provide to our members. Within the outpatient level of care providers use their clinical judgment to offer specific types of therapeutic approaches and interventions appropriate for their patients. This includes individual and group therapy sessions. Providers generally offer emergency telephone availability to their patients when necessary and understand that it is not a unique service reimbursable by most health plans.”

In states such as Minnesota, Ditty said, therapists do get reimbursed for phone coaching. He would like Highmark Delaware to follow their example.

“The phone coaching is part of a comprehensive DBT treatment,” he said. “How can they pay for part of the treatment and not all of it? It doesn’t make any sense.”

The urgency to offer effective treatment fully covered by private insurance and Medicaid and Medicare to all Delawareans has prompted Ditty to meet with anyone willing to listen.

In March, Ditty talked with Sen. Bethany Hall-Long (D-Middletown) who co-chairs a General Assembly mental health task force.

“We need to identify the challenges that providers like Dr. Ditty are facing and get help from the state to institute solutions and treatments like DBT for Delawareans,” Hall-Long said. “Medicaid doesn’t pay for persons who need treatments like DBT, but it should, so this treatment can also be part of the toolbox.”

The task force is working on addressing several mental health need areas, including suicide – how to have better prevention and treatment and how to eliminate the stigma.

“I’m really aware that suicide is a major problem in our state. We have to learn to openly talk about it, discuss the diagnosis and the treatments,” Hall-Long said. “It’s a problem that affects all of us.”

DSAMH will release its fifth report this month about the improvements it has made to state mental health care services it provides to the uninsured and underinsured clients under the state’s care. The enhancements were mandated by the U.S. Department of Justice in 2011 after 2007 investigation into violations to clients’ rights at the state-run Delaware Psychiatric Center in New Castle.

The lucky ones

Rodriguez counts herself among the lucky ones who have a good health insurance plan to pay for treatment. She laments that others may not have the right health insurance plan, such as her sister who is enrolled in Medicaid. They won’t be able to find a provider to help them.

“I know my sister is addicted to drugs and she’s been to jail,” Rodriguez said. “She is dealing with her own problems, and I know that this treatment could be good for her too, but she is on Medicaid. It’s not fair that just because you don’t have the right insurance coverage you can’t get the help to get better. It’s really not fair.”

Ditty said he has been promised a meeting with the state’s Medicaid office this month. He hopes to secure a meeting with Medicare in the future.

“I’m hopeful, but I’ve had so many meetings before. If this doesn’t work, I’ll keep on trying. I’m never going to give up,” he said. “One day, someone will listen and do what’s right.”