EDMOND, Okla. — Helen Coffey paused when the emotions became too much.
Seated at a table inside her Edmond home, she spoke about her oldest, Heather, who she said lived courageously for 38 years with a biological brain disorder called borderline personality disorder.
Heather struggled for years. She was never diagnosed or treated for the disorder. Instead, she was stigmatized and turned away from emergency rooms, her mom said. She fell through the cracks of the mental health system. Alcohol became her medication, only making matters worse.
As Coffey shared her daughter's story, she spoke with pain and purpose. But when she reflected on the day that changed her family forever, emotions overwhelmed her.
"On February the 4th of 2009," Coffey started, then closed her eyes, pinched the bridge of her nose between both hands and wept softly. When she spoke again, her voice was higher and she choked through the words.
"She took her own life," Coffey said. "Even after nine years, I have trouble with that date and remembering that."
Coffey's daughter, Heather Knapton, was one of 567 Oklahomans who died by suicide in 2009, according to figures from the Centers for Disease Control and Prevention. In the years since, the number of Oklahomans who die annually by suicide has increased by about 45 percent, twice the national percentage increase during the same period.
Today, Oklahoma has the eighth-highest suicide rate in the country, with a person, on average, taking their own life every 11 hours, according to the American Foundation for Suicide Prevention.
"We need to do something about the situation in Oklahoma," Coffey said. "And the first thing we need to do is talk about it."
The trends, mental health experts say, seemed headed in the wrong directions. While suicide rates climbed unsteadily in recent years and currently rank as the leading cause of violent deaths both in Oklahoma and nationally, public money spent on mental health services in Oklahoma saw a steady decline, the Oklahoman reported .
In fiscal year 2014, the Oklahoma Department of Mental Health and Substance Abuse Services received the first state appropriation dedicated to suicide prevention — $500,000 — meaning officials no longer had to rely entirely on grants for such efforts.
But until an $11 million increase was approved for next year's budget, the department had seen its state budget cut $52.6 million over the last four years, losing another $80.4 million in federal matching funds in that time.
Each year, between 700,000 to 900,000 Oklahoma residents need treatment for mental illnesses or addictions. Only one in three who need that help are able to access it — a gap that Terri White, the state's mental health commissioner calls "significant."
Stigma plays a role with some people reluctant to seek services.
But the largest factor is there simply aren't enough resources for people who need assistance, White said, whether that's someone who doesn't have insurance or the means to pay or someone who has insurance but their co-pays or deductibles are high or their insurance isn't appropriately covering their disorders.
"The biggest gap is that the services are underfunded," she said.
"I think the thing that is the most frustrating is that we know what to do to drive down the suicide rate," White said. "There are evidence-based prevention programs and treatment programs available that could truly make a difference, but when we only make them available to one out of every three Oklahomans who needs it, we continue to see the negative consequences of an increasing suicide rate."
When Knapton was 15, she attempted suicide by taking an overdose of over-the-counter medications. The family doctor yelled at her and told her parents she was just a "normal teenager trying to get attention."
When Knapton was 17, her parents had her involuntarily taken to a psychiatric hospital after a worrisome downward spiral. The hospital released Knapton within 24 hours, and the doctors told her parents they were being overprotective.
Knapton wanted to be perfect and functional, her mom said. She did whatever she could to hide her mental illness issues. Some relatives who had known Knapton her entire life were shocked to learn that she had a mental illness and had died by suicide, Coffey said.
"The stigma is so strong in our world that people try to cover up instead of getting help and getting what they need," Coffey said.
Knapton had sought help many times during her life, but she was unable to find treatment that worked for her or programs that would treat both her substance use and her mental illness.
When she was 35, she was diagnosed with bipolar disorder. It was a relief to her family to finally know what they were facing, but Coffey now believes the diagnosis was incorrect. She thinks her daughter suffered from a mental illness called borderline personality disorder, or BPD.
People with BPD have trouble regulating their emotions. The disorder is characterized by a pervasive instability in mood, relationships and behavior.
Knapton went to rehab programs several times, but they never worked. They weren't treating the underlying problem, her mom said.
She tried different medications, but then she couldn't perform her job. Heather was fired from a couple of companies after having mental health difficulties, her mom said. Medical bills piled up, adding stress.
"Everything goes in circles, and that's why it's so difficult," Coffey said. "Because one thing affects another thing, affects another thing, and it just becomes an unbearable, unsolvable problem."
Leading up to Knapton's death, her parents had sought guardianship of her daughters after an incident that prompted them to call police. Her parents wanted to keep the girls safe and with family because they worried the Department of Human Services might try to step in and take the girls away. Knapton's house was in foreclosure. She was having trouble with her marriage.
On the afternoon of Feb. 4, 2009, Coffey got a call from Knapton's husband. Knapton had hung herself in the garage.
Coffey doesn't know how many times her daughter attempted suicide over the years. She knew of several. Every line of defense failed her daughter, she said.
Time and again, people have told Shelby Rowe that she doesn't look like a typical suicide attempt survivor.
To deny the misconception that there is such a thing, Rowe shows a picture of herself taken about a week before she attempted to end her life in 2010.
Rowe, dressed in a formal black dress, is smiling with a couple of friends during a special event for a nonprofit organization.
"You can see how sad and depressed I look," she said sarcastically.
Rowe is a suicide prevention specialist. For the past 10 years, she has been training health professionals, educators and community members how to recognize the warning signs for people at risk of suicide.
In 2010, as she listed off risk factors while serving as director of the Arkansas Crisis Center, she started to recognize herself.
She checked almost every box. Rowe said she has experienced a lot of past trauma in her life.
Just before her 38th birthday, Rowe checked herself into a mental health hospital, but she left feeling more hopeless. On the night before Thanksgiving 2010, she went to bed planning never to wake again.
In a suicidal crisis, tunnel vision sets in, Rowe said.
"Your thinking becomes limited because the pain is keeping you from being able to process things like you normally would, so you're not seeing solutions to the problem and there's ambivalence between wanting to (live) and needing to end the pain."
Rowe did wake, a couple days later.
People who have attempted suicide are considered to have a greater risk of dying by suicide. However, about 93 percent of people who have made suicide attempts that resulted in medical care will not go on to die by suicide at a later date, Rowe said.
She shares her story in hopes of helping others, believing that sharing stories of hope and recovery can help save lives. After her suicide attempt, she knew she needed to make some changes. She bought a farm, started a nonprofit and went to a therapist to discuss her past traumas. She has focused on being kind to herself and pursuing activities that give her a sense of purpose.
As suicide prevention program manager for the mental health department, Rowe is one of the people leading the charge to prevent suicides in Oklahoma.
She pointed to several factors that could help reduce the state's suicide rate: Improving access to quality mental health care, promoting a culture where people are willing to seek treatment and limiting availability of lethal means.
About 90 percent of those who die by suicide have a mental health condition that contributes to their death, Rowe said.
In rural communities, access to care can be particularly challenging.
"There are some communities in the state that may have one mental health professional that's there in the county for four hours every two weeks," Rowe said. " ... Our community mental health centers do a wonderful job of serving a really rural population, but it is difficult."
A recent national survey showed that only about two out of five Americans with a mental health condition seek treatment, Rowe said.
"We have to fix that," she said. "If only two out of five individuals with diabetes got help, that would dramatically affect survival rates. Some mental health conditions are a degenerative, deteriorating condition, and if you don't get proper care, your state of well-being will continue to deteriorate."
Distributed by The Associated Press.