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David Hartley
David Hartley: Preventing suicide in rural areas requires a broad effort.

Not such a pastoral setting

Rural-specific issues contribute to high suicide rates

By Jessica Zigmond
Posted: July 26, 2010 - 12:01 am ET

Editor's note: This is the first of a three-part series on suicide in rural America. The second segment was published Aug. 23 and the final installment was published on Sept. 27.

Earlier this month, HHS' Substance Abuse & Mental Health Services Administration released a startling statistic: in 2007, suicides in the U.S. accounted for more than 34,500 deaths, nearly double the amount of homicides. That figure represents about a 4.5% increase in suicides from the previous year, averaging nearly 95 suicides a day in 2007.

And in rural America, the picture becomes even darker. While the Centers for Disease Control and Prevention reports that suicide is the 11th overall leading cause of death in the U.S., the American Association of Suicidology shows that suicide rates are highest in states with highly rural areas: Alaska, Montana, New Mexico and Wyoming.

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Feelings of isolation, stigmas surrounding the need to ask for help, substance abuse and the presence of guns are all contributing factors, according to experts who have studied the issue. Compounding the problem is access to services, as mental health providers and resources are often limited in rural America.

Learn more about this series on suicide in rural America (PDF)

“There is no empirical data to support any explanation,” says David Litts, who serves as director of science and policy at the Suicide Prevention Resource Center in Washington. Supported by a cooperative agreement from SAMHSA, the resource center was established to promote the implementation of the National Strategy for Suicide Prevention, a document that HHS created nine years ago to create a framework for suicide prevention in the country.

The more rural the community, “the higher the suicide rate is among the people you live with,” Litts says. “Beyond that, you can speculate: For instance, people who live in rural communities also have higher rates of gun ownership and know how to use guns. If you make a suicide attempt and use a more lethal means, you're more apt to die. Also, in a rural community, if you attempt suicide, there is less medical care available to rescue you,” he says, adding that a person's likelihood of being rescued is less than it would be in an urban community.

A 2004 study from the National Research Council, which functions under the National Academy of Sciences, supports what Litts, a retired Air Force colonel, says about the presence of guns. The study found that higher suicide rates existed in households that had firearms.

Recent statistics from SAMHSA highlighted another factor related to suicide that is a problem for two groups that live primarily in rural areas.

On July 8, SAMHSA released a new study that said although the alcohol use rate among American Indian or Alaska Native adults is well below the national average, American Indian or Alaska Native adults have a higher rate of binge drinking than the national average.

The study showed that the rate of past- month alcohol use (at least one drink in the past 30 days) among American Indian or Alaska Native adults was 43.9%, compared with the national average for adults of 55.2%, while the rate of past-month binge drinking (five or more drinks on the same occasion on at least one day in the past 30 days) was 30.6% for American Indian or Native Alaska adults compared with 24.5% for the national average.

The level of illicit drug use was also found to be higher among American Indian and Alaska Native adults: 11.2% compared with 7.9% for the national average. A white paper released by SAMHSA two years ago cited mental illness and substance abuse as the two most significant factors for suicide. And while the research showed that 95% of individuals with a mental illness and/or substance use disorder will never commit suicide, evidence shows that as many as 90% of individuals who do commit suicide experienced a mental or substance use disorder.

Adding to problems of depression, mental illness and substance abuse are the barriers to receiving proper treatment in rural areas, such as reluctance to asking for help and a lack of resources and mental health professionals.

“It's just not something that is talked about: incest, domestic violence, sexual violence—it might be whispered about, but people don't talk about it, so they don't talk about the resources,” says Jacqueline Gray, an assistant professor in the Center for Rural Health at the University of North Dakota in Grand Forks. “It's that you're somehow defective if it's a mental health issue rather than a physical issue,” she says, adding that at least five Native American reservations have had one or more “clusters” of suicides in the past six years. Clusters are cases in which three or more suicides occur closely, such as in the same family or among youth who spend time together.

“Once someone in your social sphere commits suicide, it makes it more of an option to the problem,” Gray says. “Where you might never have considered it, now it's a possible solution.”

Then there is the scarcity of mental healthcare providers in rural locations. David Hartley, director of the Maine Rural Health Research Center at the University of Southern Maine in Portland, has conducted research on rural behavioral health for 16 years.

“In general, the prevalence of depression or more serious disorders—it's pretty much the same in rural and urban areas,” Hartley says. “It's not that they're in greater need because of illness, but either because they don't choose to seek services or the services aren't there in the first place,” he adds. “There are vast areas in the West where there isn't any.”

As Hartley explains, preventing suicide in rural areas requires a broad group effort in order to be effective.

“It's not just the mental health system that has to confront this,” Hartley says. “It's churches, it's the farm credit bureau, law enforcement—all of these people will be coming upon people in crisis.”

In addition, all rural communities are not alike, so it's important to develop solutions that are tailored to a certain region, Litts says.

“We guide whatever organization we're working with through a strategic planning process where you look at the data around the problem in your area; you look at the risk factors that can be modified; you look at public will to make some changes in those risk factors and protective factors,” Litts says, “so you choose interventions that are acceptable and likely effective in that community you're working on.”



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