The Animas River, in La Plata County, outside Durango, Colo. (Bonnie Jo Mount/The Washington Post)

UNNATURAL CAUSES | SICK AND DYING IN SMALL-TOWN AMERICA: Since the turn of this century, death rates have risen for whites in midlife, particularly women. In this series, The Washington Post is exploring this trend and the forces driving it. Read the other stories in this series here.

The river gallops past ghost towns and plunges through canyons of quiet before tumbling into the old mining town of Durango. Legend has it that the Spanish christened these waters more than 300 years ago to honor a small band of conquistadors who died on its banks without receiving the sacrament of last rites. They called it El Rio de las Animas Perdidas.

The River of Lost Souls.

Today, some 53,000 people live in Durango and the surrounding county of La Plata. And all along the Animas, people are still dying before their time, particularly women in midlife, succumbing not to diabetes or heart disease, but to suicide.

Two-and-a-half times as many people die by suicide as homicide in this country; among whites in 2014, it was nearly nine times as many, according to the Centers for Disease Control and Prevention. Although more men than women take their own lives, the rate of suicide has nearly doubled among middle-aged white women since 1999 — rising from 7 per 100,000 to 12.6 in 2014 — helping to explain a startling increase in their early mortality.

The numbers are even worse for middle-aged white women with a high school diploma or less. For them, the suicide rate has more than doubled over the past 15 years, according to a Washington Post analysis of federal health data. Most of the victims lived in small towns and rural areas, particularly in the Southeast and in mountain states, where social isolation can be acute.

Colorado has the fourth-highest suicide rate in the nation for white women ages 45 to 54. Among Colorado counties with a population of at least 30,000, La Plata has the highest.

Since 2007, 14 middle-aged white women have killed themselves here. The Post looked at half of those cases and found striking commonalities: Most worked physically demanding jobs. Most suffered from chronic pain. And most struggled with mental-health issues that, surviving friends and relatives say, were addressed through psychiatric medications that were ultimately ineffective.

Nationally, many mental-health experts have raised concerns about the growing use of such medications for everything from insomnia to ordinary loneliness. Between 1999 and 2013, psychiatric drug prescriptions shot up by 117 percent.

The number of prescriptions written by non-psychiatrists also has risen. As many as 80 percent of all antidepressant prescriptions are written by physicians who are not psychiatrists, multiple studies have found, and doctors often give the drugs to people who have received no psychiatric diagnosis. Studies also show that the drugs work only about half the time and can produce side effects, such as anxiety and sleeplessness, that mimic worsening symptoms.

Women are far more likely than men to receive these prescriptions: In the United States today, nearly 1 in 4 white women ages 50 to 64 is taking an antidepressant, according to federal health officials.

No expert suggests that these medications are driving the uptick in suicide among this population. Research into that question is difficult, because many women on psychotropic drugs are already prone to depression and suicide. PhRMA, which represents the nation’s biggest drug companies, declined to comment for this story.

Christine Moutier, chief medical officer of the nonprofit American Foundation for Suicide Prevention, said the presence of multiple medications may suggest that the patient’s mental illness was particularly difficult to treat.

“When I hear that someone is on more than three psychotropic medications, that tells me their doctor was going after the condition because the person didn’t respond to the first medication,” Moutier said. “There is a case to be made for rational polypharmacy.”

However, Moutier added that multiple prescriptions can also suggest “suboptimal treatment.” And for women who believe the drugs hold the promise of a cure, other medical experts said, their failure can induce a withering spiral of hopelessness.

“There’s all kinds of reasons to be depressed, and doctors are not attending to them anymore,” said Joel Paris, a professor of psychiatry at Canada’s McGill University. “What doctors are being told is, if the patient isn’t getting better, then you need to add another two or three [medications] to the regime.

“The issue that antidepressants help about half the time is absolutely right.”

The western slope of the Rockies has always had higher-than-average suicide rates, people venturing westward in search of excitement or escape and finding neither. For Pamela Beckert, Colorado was just another place to start over.

Born in Ohio, Beckert grew up in Arizona. She was married twice but largely raised her son on her own. After Beckert’s father died in the 1990s, and with her son grown, she became a nomad, moving first to Fort Worth, then to Durango. Nothing felt permanent, including her jobs — a waitress in a bar, a process server, a security guard for Planned Parenthood. She had trouble paying rent, and sometimes her moods vacillated wildly. Through Medicaid, she received psychiatric medication from a Durango health clinic: Wellbutrin to raise her spirits; Lamictal to even out the mood swings; Klonopin for anxiety; Seroquel, an antipsychotic, to sleep.

Sometime in the months before her death, Beckert stopped taking all of them and began stockpiling the pills.

“It had become so dark at the end,” said Beckert’s son, Sean Dillman, who lives in Arizona. “I look back and I’ll always wonder what I could have done. But her demeanor was always the same. . . . I had no idea, no clue this is where she was at.”

No longer able to afford her apartment, Beckert bunked with a friend and worried about where she would go next. When she asked a caseworker at the clinic about temporary housing, the young woman suggested Beckert live out of her Jeep at the back of the vast Walmart parking lot. Surely no one would notice her there.

Pamela Beckert died of an overdose in this parking lot in Durango, Colo. (Bonnie Jo Mount/The Washington Post)

Wendy Faye Miller passed that Walmart on Route 550 nearly every day for decades. Most often, she was driving home from her bartending job at the Purgatory Mountain ski area, the road weaving around the Animas, where the outdoorswoman loved to raft and fish.

Miller couldn’t wait to move to Durango. She left Waterford, Mich., at 17, missing her high school graduation to follow the man who would become her first husband. That was 42 years ago.

About five miles east of downtown and half a mile past a sign that reads “Pavement Ends,” Miller lived in a mobile home until last December. A sagging porch and a tin roof secured with concrete bricks betray the home’s age. Most days, the only sounds are distant dogs barking at strange cars and the crunch of pickups passing on the unpaved road. When she lived here, Miller owned two horses until she was forced to sell them to pay bills. Her most beloved possession: a pearly white Harley-Davidson motorcycle.

“She loved to ski. The outdoor lifestyle. She never grew out of it. Ever,” said her only sibling, younger sister Lorrie Searle, who still lives in Michigan.

In addition to tending bar, Miller shoveled snow in the winter and sprayed mosquitoes for the county in the summer. Nearly all her life she also cleaned homes and businesses, including the office where her daughter, Autumn Concepcion, now works. It wasn’t easy: Miller had had two back surgeries for injuries suffered while breaking up a bar fight and falling down the stairs carrying a keg of beer.

Autumn Concepcion’s mother, Wendy Miller, pictured in rear, killed herself at age 59. Autumn said she was very close to her mother and continues to grieve. (Bonnie Jo Mount/The Washington Post)

The woman with the quick smile didn’t like being alone. She was an alcoholic, according to family and friends, but careful to conceal her misery. Only her daughter saw her mother’s sadness.

“I could see her in town and she’d be fine, laughing, and then talk to her 20 minutes later at home, and it would be totally different,” Concepcion said. “Even her voice would change.”

Miller’s daughter suggested she see a mental-health counselor in Durango. More than half of all counties in the United States — all of them rural — have no practicing psychiatrists, psychologists or social workers, according to a 2013 federal report. In La Plata County, only one mental-health clinic accepted Medicaid. Miller, unfortunately, qualified for Medicaid only part of the year, when she wasn’t earning wages above the federal poverty limit. Otherwise, she would have to pay on a sliding scale, and the scale didn’t slide quite enough. Miller visited just once.

“She hid her pain,” said Crystal Andasola, a close friend. “She was a broken person, with a broken spirit, a broken soul.”

Charlotte Sieber hanged herself when she was 54. (Family photograph)

Charlotte Sieber fought depression for years, and then she battled her own medications. The Sweden native was a flight attendant when she met her future husband, Brad, more than 30 years ago. They settled in a small, fruit-tree-laden enclave just north of downtown Durango, where they had two children. He was a UPS driver; she found a job in a local clothing store. But 20 years ago, after injuring her neck and back in a series of automobile accidents, she could no longer work, and she spiraled into depression.

“If she had a great day, it was usually two or three weeks before there was another,” said Sieber’s husband.

The psychiatric medications doctors prescribed seemed to work only for a short time (when they did at all): the antidepressant Effexor, Wellbutrin, Klonopin, Seroquel. There were others, too, but none offered long-term relief.

“Multiple drugs overload the system in ways we can’t predict,” said Rene Muller, a psychologist at Johns Hopkins. “Everyone metabolizes drugs differently, which also affects how they interact with each other.”

Four years ago, Charlotte Sieber met Jennifer Roeder, who told of her own travails trying to come off psychiatric medications when they failed to help her feel less depressed.

“It was the first time she heard that maybe the drugs were hurting, not helping,” Roeder said.

Sieber began to slowly wean herself off her many medications, tapering the drugs one at a time, according to family and friends, though she often had to stop to let her body and mind recover.

“It’s really hard to withdraw from antidepressants,” said New York psychiatrist and pharmacology expert Julie Holland. In some cases, “people feel like cold water is running down their spine. They can feel their brain sloshing around, or electric zaps in their head.”

By July 2015, Sieber had successfully discontinued all but one of her psychiatric medications.

“One of her worst [side effects] was sleep. She could not sleep,” said Pati Wolfe, who often joined Sieber in the struggle to withdraw from drugs. “This went on for months and months. Maybe a couple of hours a night was all she would get.”

It was so bad that Sieber had to move out of the bedroom she shared with her husband so he could get some sleep. Heart palpitations, obsessive worrying and anxiety clouded her nights. She lost weight and sometimes told friends it was too hard to talk to them.

Toward the end of July 2015, Sieber texted Roeder: “I know I’m in a state of shock, never been this sick in my whole life. Of course the long process of tapering (6 years in Nov.) has worn me out.”

Over the next two months, Sieber mostly retreated to her room, where she wrote in a journal and painted delicate pastoral scenes on seashells she had collected at the shore. At other times, she sat out back on an island deck, under the scrub oak and beside a stream that branches off a creek that branches off the River of Lost Souls.

Seashells painted by Charlotte Sieber in Durango, Colo. Her husband, Brad, said she was happiest at the beach. (Bonnie Jo Mount/The Washington Post)

Pamela Beckert, 54, died Sunday, Jan. 15, 2013, after telling a friend, with whom she was living, that she might be late.

“It’s going to get really, really cold. Don’t wait up for me,” Beckert told her. “I know my way home.”

A week later, friends found her body, clad in a white winter jacket and jeans, a pair of mittens and clogs beside her. Beckert had bought a light blanket at Walmart and a cup of tea at Starbucks, downed dozens of pills from six different bottles of psychiatric medication, then lay down in the back of her Jeep Wrangler — at the far end of the Walmart parking lot.

Wendy Miller, 59, died on Monday, Dec. 14, 2015. It snowed hard all day in La Plata County, and Miller fell while leaving a house she had cleaned that afternoon. She was scheduled that evening to clean her daughter’s workplace, but Concepcion called to tell her they’d closed early. Miller asked her daughter to let her know when she got home safely, and at about 6 p.m. she did. Her mother texted back: “good, thank you, xoxo.”

Miller was probably already home by then, after stopping to buy a fifth of McCormick vodka, which she nearly finished that night. About 9 p.m., she was on Facebook, making plans for her 60th birthday party in January. At one point she smoked a little pot, which usually helped her sleep. Then, sometime after 9:30 p.m., Wendy Miller crawled into bed, put a .38 Special in her mouth, and pulled the trigger.

Her shopping list was still on the kitchen table: dish towels, laundry soap, milk.

Brad Sieber reminisces about his wife, Charlotte Sieber, at his home in Durango. Sieber has struggled to reconcile his feelings about her death: “I'm a fixer. I fix things. But I couldn’t fix Charlotte.” (Bonnie Jo Mount/The Washington Post)

No one knows what Charlotte Sieber, 54, was doing in the hours before her death on Nov. 11, 2015. She was alone in her bedroom that Wednesday afternoon, with her 26-year-old son on the computer in the next room.

Two weeks earlier, her husband, Brad, had called a suicide hotline. They told him to take her to the hospital, but he knew that was the last place his wife would go, afraid she’d be given even more medications.

The final text Jennifer Roeder received from her friend had come five weeks earlier. Sieber had told her: “I’ve been really really bad, however it makes me feel worse talking about it . . . Trust me, I just need the pain and suffering (anxiety/fear/panic) to go away, not to mention the insomnia!”

Sieber hanged herself from a rope thrown over a rod in a small closet in her bedroom. Later, her husband found a belt from one of her dresses, torn in half and thrown in the trash. It had taken her two tries to die.

After his wife’s death, Brad Sieber’s anger banged its fist against his grief. Furiously, he scoured the house for the bottles of pills he believed had driven his wife to take her life. He found them in the medicine chest, the kitchen cabinets, the drawers of her desk — two dozen of them, maybe more — and poured them all, one by one, down the toilet. Then Sieber threw the bottles and all his wife’s medical files into a garbage bag and dragged the load out of the house.

Beyond the rock garden, the apple trees and the stream from the creek from the River of Lost Souls, he spilled all those decades of pain into the backyard fire pit. And as the pyre burned into the twilight, Brad Sieber watched and wept.

Dan Keating and Alice Crites in Washington contributed to this report.