March 7, 2008 -- The still waters of the Great Salt Lake run deep -- and dark.
Take Wendy, a 40-year-old teacher and mother of three from Utah County. To all appearances, she led the perfect life. Just as she was expected to, she went from high school cheerleader to Mormon missionary to wife and mother.
"But life has a funny way of not being perfect," she said. "Three years into my marriage my husband was drinking, using drugs and stepping out on me.
"I knew I was depressed and needed help, but there is a stigma about depression in this area," said Wendy, who asked that ABCNEWS.com not use her last name. "People think it's a sign of weakness. It means you're not capable of being a good mother or wife or teacher."
Wendy's secret is Utah's secret. The postcard image of Utah is a state of gleaming cities, majestic mountains and persistently smiling people. But new research shows a very different picture of the state, a snapshot of suicide and widespread depression.
A recent study by Mental Health America, the country's oldest independent mental health advocacy organization, ranked Utah the most depressed state in the country.
Another survey released last week by drug distribution company Express Scripts found that residents of Utah were prescribed antidepressant drugs more than those of any other state and at twice the national average.
According to MHA, some 10.14 percent of adults in Utah "experienced a depressive episode in the past year and 14.15 percent experienced serious psychological distress. ... Individuals in Utah reported having on average 3.27 poor mental health days in the past 30 days."
The reason for Utah's mass depression, however, is unknown.
"The truth is, we don't know why," said Dr. Ted Wander, spokesman for the Utah Psychiatric Association.
Neither study was broken down by gender, but nationally women are twice as likely to be diagnosed with depressive disorders as men, experts told ABC News.
Psychiatrists point to several factors that could contribute to Utah's high levels of depression: limited mental health resources, restricted access to treatment as a result of cost, poor quality of resources and a varied list of other factors, including an underfunded educational system and a culture deeply rooted in the Mormon faith.
"Availability to resources, a lack of professionals and barriers to treatment, including the ability to pay all drive up instances of depression," said Dr. Curtis Canning, a Logan-based psychiatrist and former president of the Utah Psychiatric Association. "But there is also -- especially when it comes to women and girls -- a cultural factor."
Seventy percent of Utah's residents are Mormon. When Express Scripts issued its first national survey of prescription drug use in 2002, it sparked a heated debate across Utah about what, if any role, the church played in the state's high dependence on antidepressants such as Prozac and Zoloft.
"In Mormon culture females are supposed accept a calling. They are to be constantly smiling over their family of five. They are supposed to take supper across the street to an ill neighbor and then put up with their husband when he comes home from work and smile about it the whole time. There is this sense that Mrs. Jones down street is doing the same thing, and there is this undercurrent of competition. To be a good mother and wife, women have to put on this mask of perfection. They can't show their tears, depression or agony," Canning said.
"Obedience, conformity and maintaining a sense of harmony" are unspoken but widely recognized behaviors, which all contribute to what he calls "the Mother of Zion syndrome."
When Wendy first started seeking professional help and was put on Zoloft 10 years ago, she felt the sting of shame even from her own family members.
"Marriage and family are so important that there was a huge amount of pressure to make things work. I was supposed to try harder, and buck up and that would make me happier and keep my husband from abusing me," she said.
"There are expectations from the community, but mostly from other women," she said. "It doesn't come down from the church necessarily, but it's passed from mother to daughter. My family was reluctant to see me taking the drugs, but since seeing me at my worst, they now encourage me to take my meds."
The Church of Jesus Christ of Latter Days Saints, however, says the high number of prescriptions is a result of people receiving the drugs they need in Utah more than in other places.
"I don't think it's clear that there's a crisis in Utah," said Brent Scharman, a psychologist and the assistant commissioner of LDS Family Services, a church network that provides counseling. "You've got one camp that says there is more depression and another camp that says we just have more consumers."
Scharman said studies on organized religion and depression found that religious people were generally happier than nonreligious people, and that held true for Mormons.
"It always boils down to the issue of what influence the LDS lifestyle has on the depression phenomenon," he said. "Non-LDS and some LDS people say this is a kind of driven lifestyle and that we push too hard and smile too much. But studies show, and those living it out see, that religion is good support. It creates a positive network and helps people get through crises and deal with long-term problems.
"Are there people who feel 'I'm not living up to the LDS ideal,' or 'I'm not living up to my family's expectations'? Absolutely, there is no question. But having done counseling outside the LDS community, I saw people there, too, who were depressed because of perfectionism," he said. "I wouldn't say it is any worse here than in more diverse communities."
The MHA study evaluated information from the Centers for Disease Control and Prevention, each of the 50 states and Washington, D.C., and factored in suicide statistics to determine each state's "depression status."