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Living High and Feeling Low

Altitude, Suicide, and Depression

Kious, Brent M. MD, PhD; Kondo, Douglas G. MD; Renshaw, Perry F. MD, PhD, MBA

doi: 10.1097/HRP.0000000000000158

Learning objectives After participating in this activity, learners should be better able to:

• Assess epidemiologic evidence that increased altitude of residence is linked to increased risk of depression and suicide

• Evaluate strategies to address hypoxia-related depression and suicidal ideation

Suicide and major depressive disorder (MDD) are complex conditions that almost certainly arise from the influences of many interrelated factors. There are significant regional variations in the rates of MDD and suicide in the United States, suggesting that sociodemographic and environmental conditions contribute. Here, we review epidemiological evidence that increases in the altitude of residence are linked to the increased risk of depression and suicide. We consider the possibility that chronic hypobaric hypoxia (low blood oxygen related to low atmospheric pressure) contributes to suicide and depression, which is suggested by animal models, short-term studies in humans, and the effects of hypoxic medical conditions on suicide and depression. We argue that hypobaric hypoxia could promote suicide and depression by altering serotonin metabolism and brain bioenergetics; both of these pathways are implicated in depression, and both are affected by hypoxia. Finally, we briefly examine treatment strategies to address hypoxia-related depression and suicidal ideation that are suggested by these findings, including creatine monohydrate and the serotonin precursors tryptophan and 5-hydroxytryptophan.

From the Department of Psychiatry (Drs. Kious, Kondo, and Renshaw) and Brain Institute (Drs. Kondo and Renshaw), University of Utah; VISN 19 Mental Illness Research, Education and Clinical Center, Salt Lake City Veterans Affairs Medical Center, Salt Lake City, UT (Dr. Renshaw).

Original manuscript received 21 October 2016, accepted for publication subject to revision 9 January 2017; revised manuscripts received 24 January and 10 February 2017.

Correspondence: Brent M. Kious, MD, PhD, 501 Chipeta Way, Salt Lake City, UT 84108. Email:

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© 2018 President and Fellows of Harvard College
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