REGIONAL- The growing problem of rural suicide and what can be be done to reverse the trend was the subject of an expert panel discussion earlier this month, sponsored by the Center for Rural Policy and Development, or CRPD.
More people are dying by their own hands in rural parts of the state, and nowhere is that trend more evident than in northeastern Minnesota, which has the state’s highest rate of suicide.
An analysis created by CRPD vice-president for research Marnie Werner and Tracie Rutherford Self, a faculty member at Minnesota State University-Mankato, was the focus of discussion. Werner reviewed statistics derived from the report detailing the scope of the problem, as well as dynamics particular to rural areas that contributed to higher suicide rates.
“A lot of this has to do with diseases and deaths of despair,” Werner said. “That was a term that was coined in 2015 by two researchers who noticed an acute rise in the number of suicides, the number of deaths by drug poisoning or overdose, and alcohol related diseases. These have been rising steadily over the past 25 years. Since 2018, the higher rates (of suicide) have been in northeast Minnesota and northwest Minnesota. The southern metro counties actually have the lowest rates in the state.”
Among the higher risk groups identified by the Minnesota Suicide Prevention Task Force, Werner highlighted data about a group prevalent in northern Minnesota: Native Americans.
“Their suicide rate has been higher than the general population for many years, and the rate in Minnesota for Native Americans is higher than the average rate for Native Americans in the U.S. in general, too.”
Indeed, the report shows that since the year 2000, Native Americans in Minnesota have had suicide rates higher than the national Native average for all but two years. In 2018, Native suicides in Minnesota doubled the national rate. Possible factors for this disparity include a lack of economic opportunities and being in small, isolated populations, increasing the chances of experiencing chronic distress.
Werner said farmers are another demographic susceptible to higher rates of suicides.
“Farmers were a big topic of discussion before the pandemic, and they’re still an issue,” Werner said. “Farmers struggle with a unique set of issues, including volatile income, fear of losing the farm and stigma around mental health. And then access to firearms. In rural areas, there are simply more guns. Taking your own life is an act of impulse, and if you have a gun at hand, it’s easier to make that happen. In entirely rural areas there’s a higher percentage of people using firearms for suicide. When you take firearms out of the mix you can see that the suicide rate drops considerably.”
Werner described multiple aspects of rural culture than can contribute to suicide, including:
• A high value placed on independence and self-reliance.
• Isolation.
• Lack of trust of those outside of one’s social network.
• The lack of anonymity.
• The stigma surrounding going to mental health providers.
Self said how we do or don’t talk about suicide is also a factor.
“I think there’s multiple facets at play here, but if we could look at one thing in particular, the thing I would come back to consistently is the fact that talking about suicide is still incredibly taboo,” she said. “So many people simply don’t have conversations when they’re starting to have thoughts of suicide. They will keep that to themselves. Suicidal ideation is incredibly common. I think probably everybody on the planet at some point in their life has had the thought of suicide, and for some people that happens more pervasively, but we still don’t have the conversations. That’s one of the key places we have to start in order to really address the epidemic.”
David Goehl-Manolis, Suicide Prevention Coordinator for the National Alliance on Mental Illness, expanded on how common suicidal behaviors are.
“When we talk about the statistics, the number of people who have attempted suicide and survived is, I think the ratio is around 25 people who have attempted and survived to one person who has passed, and so you can imagine the millions of people that have attempted it who survived. But then there’s even another level to it, and those are people that have had serious thoughts of suicide but haven’t attempted it. The last statistics I saw from the Suicide Prevention Resource Center, there was over 12 million people in 2021 who had serious thoughts of suicide. It’s very common to have thoughts of suicide as just a way of feeling overwhelmed by the life problems that somebody might be encountering.”
Goehl-Manolis echoed Self’s comments that there needs to be a greater comfort level in having discussions about suicide.
Panelist Monica McConkey, a licensed marriage and family therapist and rural mental health specialist, noted that suicide has a troubling ripple effect.
“For every death by suicide, there are a number of survivors that are impacted,” she said. “And we know that their risk for suicide attempts or death by suicide also increases when they have lost a friend or a loved one to suicide. So that compounds the issue.”
McConkey said the report “hit the nail on the head” when describing contributing factors to suicide.
“There’s a lack of services, lack of resources, increased isolation, and stigma is still alive and well in our rural communities,” she said. “There are lots of reasons why this sense of hopelessness is really pervasive among so many people.”
Self noted that there was actually an unexpected drop in the suicide rate at the beginning of the COVID pandemic.
“The anticipation was that we would see a pretty dramatic increase in suicidal deaths, and we didn’t actually see that,” she said. “Except, we did.”
While the overall numbers did decrease among white middle-class men, Self said that when they got into the data, it showed that the suicide rate actually increased for marginalized populations.
“It increased for those with low (socioeconomic status) who might not have had the same access to resources and who were more stressed by the pandemic,” Self said. “So, what we saw was a drop, but that drop really is a bit deceptive because it was really only a drop for people with the greatest access to resources.”
Access to local resources was an issue that panelists repeatedly came back to, both as a current problem and a potential solution.
“Individuals who die by suicide from rural communities almost never have a mental health diagnosis prior to their death,” said Self. “One of the things we know is that they’re not seeing a mental health professional. And, again, I go back to that isolation piece, that we’re not having these conversations. And if there is a lack of availability of providers in that area, who do I refer to?”
Werner said that access is also hampered by lower income levels in rural areas, and people may not have access to health insurance that covers mental health services.
Transportation is another critical component for accessing help, and people with low incomes in rural areas may have unreliable transportation or limited access to cumbersome public transportation alternatives, according to Self.
“If you can’t get to your practitioner’s office, it’s really hard to actually access the care that you need,” she said.
Telehealth isn’t an ideal alternative for rural areas because of limited broadband access and also because in-person interactions facilitate a sense of connection that helps people to tell their “deepest, darkest secrets,” Self said.
Listeners were interested in hearing strategies to address the problem of rural suicide, and panelists were ready with a number of suggestions:
• Increase the diversity and cultural competence of the mental health workforce serving rural clients.
• Collect more extensive data from marginalized populations to enhance a database currently skewed toward white middle-class males to more accurately identify, describe and address differences for rural areas.
• Develop pay parity to attract more people to the mental health workforce.
• Increase public awareness of what words and language are best used when discussing suicide.
• Acknowledge that suicide is uncomfortable, and make conversations about suicide a normal, everyday part of conversation to reduce stigma and isolation.
• Facilitate collaborative relationships between mental health professionals and school staff and clergy.
• Provide more tailored training, both in-person and online, directed to trusted anchor members of communities who may be more likely to encounter individuals with suicidal thoughts.
• Increase awareness of the 988-help line.
• Develop and utilize mobile mental health crisis teams.
• Use an integrated health care approach promoting relationships between behavioral and medical health professionals.
• Promote gun safety education and take steps to make gun access more difficult to help prevent impulsive actions, including the use of Minnesota’s red flag law.
“When we look at rural communities, we have issues with accessibility, availability, and acceptability,” Self said. “When we start to use those informal resources, we start to increase the acceptability of talking about those things in rural areas.”
“Just notice the people around you,” McConkey said. “We get so into our busyness and our tasks and what we need to focus on, and a lot of people are hurting right now. Any of us can notice if they’re hurting and be there with an invitation to talk and listen.”
To access the full written report “The Suicide Epidemic in Rural Minnesota: How we got here and how we move forward,” go to the Center for Rural Policy and Development website at www.ruralmn.org. A recording of the webinar can be viewed on the center’s YouTube channel.