In a year when headlines have been dominated by school shootings and other homicides, a much more common form of fatal violence has largely faded from the public’s view.
But suicides outnumber homicides by almost three-to-one, their numbers growing by 28% between 2000 and 2015. And the burden does not fall evenly: America’s suicide rate has been consistently higher in rural than urban areas since at least 2001.
But a growing body of literature suggests that suicide, even in isolated communities, is preventable. So how can the US hit its goal to reduce suicide by 20% by 2025?
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Rural risk, rural resilience
A 2014 systematic review of rural suicide literature found that geographic isolation, access to firearms, a dearth of mental health professionals and stigma around mental illness all contribute to suicidal behaviours, and are either unique to or more prevalent in rural areas.
Limiting these phenomena is crucial to controlling the suicide rate.
But the same review also concluded that rural areas have a set of distinct characteristics linked to a reduced risk of suicide, known as protective factors. The strong sense of community in many small towns, a more profound connection with nature, and an investment in personal or family honour all seem to protect against suicide attempts.
“It’s almost paradoxical,” said Jameson Hirsch, author of the review and Professor of Suicidology at East Tennessee University, “because some of the risk factors are also protective factors and vice versa.”
“Purely medical approaches won’t work if communities have no medical infrastructure”
Small communities can mean stronger community bonds. But living in one can also compound the fear of being stigmatised in a place where gossip travels fast. The culture of self-reliance that often characterises rural areas can build resilience to mental health challenges, or it can compound the burden by making it harder to discuss one’s struggles openly.
Any successful prevention strategy will minimise risk factors and boost protective factors, but what works in cities won’t necessarily work in small towns or farming communities, said Jerry Reed, co-author of the 2012 National Strategy for Suicide Prevention.
Purely medical approaches won’t work if communities have no medical infrastructure, and mental health support is elusive for many. A recent paper in the American Journal of Preventive Medicine found that 65% of non-metropolitan counties had no psychiatrist, and 47% had no psychologist.
An effective solution requires lateral thinking. “Maybe we need to get the faith community involved; maybe we need to make sure meals-on-wheels volunteers know how to make a referral to social services agencies; and maybe we need more telehealth — more technology to help people access faraway services,” Reed said.
Hover over each line to reveal the state. Click a line to isolate that state’s suicide rate over time.
Signs of hope
At a state level, some interventions show promise.
In Oregon, Idaho and Washington, the Rural Telemental Health Program (RTMH) provides counselling and therapy services to military veterans who cannot access face-to-face help — whether due to distance or social stigma. Support is provided via phone, email or video conferencing. From 2010 to 2013, RTMH reached 1,754 veterans and spared more than one million miles of travel for its service users.
Another successful approach was pioneered in a remote borough of Alaska, targeting Alaska Native teenagers.
This young cohort’s suicide rate was seven times the state average in 2008. But the Teck John Baker Youth Leaders Program taught teens to call out bullying in their communities and provide support to people in harmful relationships, as well as how to help peers who were struggling with substance abuse. The total number of suicides in the borough dropped from 8 in 2008 to 5 in 2009 then to zero, where it has remained since.
And reducing access to lethal means has shown promise both in the US and abroad. Gun locks, freely distributed by numerous counties across the US, can delay someone in a time of crisis — a known protective factor against suicide attempts.
“Rural suicide is something of a token issue”
But according to Reed, no single intervention is likely to significantly reduce the rate of suicide across a community, let alone a state. “You have to deliver a bundled set of interventions and not just one. You can’t only work with a patient in crisis — sometimes it’s the system that’s in crisis.”
Systemic reform was at the heart of the 2012 National Suicide Prevention Strategy, yet according to Reed, no state has yet implemented a comprehensive state action plan.
That matters when the literature suggests that the only way to effectively reduce suicide rates is to work across multiple axes. According to Reed, that means embedding suicide prevention strategies into an array of frontline services, from community doctors to farming information centres, local churches, and in schools and colleges across rural areas.
One example has come in the form of Zero Suicide, a set of strategies designed to improve suicide prevention within health systems, after research suggested that patients were leaving hospitals and taking their own lives soon after.
Zero Suicide comprises seven strategies, including helping professionals identify suicidal behaviours, preparing treatment and aftercare plans, and rigorously analysing regularly collected outpatient data to monitor progress. Zero Suicide is already in use by over 200 healthcare and behavioural heath organizations, with more to follow.
Policy, politics and priorities
Overall, progress is lagging.
That isn’t entirely surprising, according to Hirsch. “Rural suicide is something of a token issue,” he said. “It’s not that people don’t care, it’s that constituencies and budgets fall in metropolitan areas.” Even where there is a will, there often isn’t a way.
Without concerted efforts at every level of American government, the suicide rate looks set to rise — and the gap between rural and urban will likely continue to widen. — Edward Siddons
(Picture credit: Pixabay)