This edition of A Kansas Twist is the first of a two-blog series covering suicide prevention in rural areas of the United States and Kansas. This first blog focuses on federal efforts, while the second will focus on state-level approaches, policies and programs that Kansas policymakers and other stakeholders may consider when working to reduce suicide rates in rural communities. It follows the recently published issue brief Urban-Rural Differences in Suicide Rates and Leading Means in Kansas.
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In 2019, one person in the U.S. died by suicide every 11 minutes. The 10th overall leading cause of death in the country, suicide is a complex public health challenge that has far reaching impacts on individuals, families and communities. While suicide has impacted communities and families of all sizes and demographics, suicide rates have been higher in nonmetropolitan communities for the last two decades and have increased faster since 2007. In Kansas, the most rural parts of the state, known as Frontier counties, have higher suicide rates than the most populous counties, and the suicide rate by firearms in these Frontier counties is higher than anywhere else in the state.
In 2017, the National Advisory Committee on Rural Health and Human Services recommended that the Substance Abuse and Mental Health Services Administration (SAMHSA) “include rural-specific research and considerations for prevention into the National Strategy for Suicide Prevention.” The Advisory Committee also recommended that the U.S. Department of Health and Human Services (HHS) be required to “conduct a national comprehensive evaluation that assesses existing state and tribal efforts to reduce rural suicide rates and that identifies successful evidence-based, rural-specific strategies.” Nevertheless, over three years later, rural-specific suicide prevention policies and strategies at the federal and state levels remain limited.
The federal government, through the National Institute of Mental Health (NIMH), the Centers for Disease Control and Prevention (CDC) and other agencies, plays an important agenda-setting, legislative, funding and resource-sharing role for suicide prevention efforts nationwide.
The 2012 update of the National Strategy for Suicide Prevention, a report of the U.S. Surgeon General and the National Action Alliance for Suicide Prevention, serves as a roadmap for national suicide prevention efforts. Organized in four interconnected strategic directions and advanced by specific goals and objectives, the national strategy is meant to represent a “comprehensive, long-term approach to suicide prevention.” Despite higher rates of suicide, rural populations are not included in the report as one of the 11 identified groups with increased suicide risk.
The federal government has, through legislation, supported suicide prevention priorities for decades. Past legislation includes Senate Resolution 84 and House Resolution 212, which in 1997 recognized suicide as a national problem, and the Garrett Lee Smith Memorial Act, which in 2004 created the state, tribal and campus suicide prevention grant programs.
Earlier this year, Congress turned its attention to suicide prevention and the unique needs of veterans. On June 30, President Joe Biden signed the Sgt. Ketchum Rural Veterans Mental Health Act of 2021, a bill co-introduced by Kansas Sen. Jerry Moran, named after Sgt. Brandon Ketchum, a decorated Marine veteran who, as a civilian, traveled around the country giving talks on veterans mental health. On May 27, 2016, Sgt. Ketchum, who had struggled with Posttraumatic stress disorder (PTSD), depression and substance abuse for years following tours of duty in Iraq and Afghanistan, sought emergency inpatient psychiatric care at an Iowa Veterans Affairs (VA) hospital. After being denied treatment due to lack of resources, he died by suicide. The Ketchum Act directs the VA Secretary to expand the Rural Access Network for Growth Enhancement (RANGE) Program of the VA and to conduct a study to assess the mental health care resources of the VA that are available to veterans who live in rural areas.
In addition to providing funding to support health care access, including mental health services, the federal government supports suicide prevention work throughout the country. The Comprehensive Suicide Prevention Program grant, funded by the National Center for Injury Prevention at the CDC, funded nine recipients in 2020 — mostly state departments of health — to implement and evaluate a comprehensive public health approach to suicide prevention. The program requires grantees to identify one or more “vulnerable populations,” one of which may be rural communities.
SAMHSA provides several funding opportunities for suicide prevention, including the Garrett Lee Smith (GLS) Campus Suicide Prevention grants. One GLS campus grant awardee in 2020 was Fort Hays State University — located in rural Northwest Kansas. The Farm and Ranch Stress Assistance Network (FRSAN) Program, recently launched by the United States Department of Agriculture (USDA), provides grants to support programs that provide behavioral health services for agricultural workers in crisis.
Through the Federal Office of Rural Health Policy, the federal government supports the Rural Health Information Hub, a nonprofit organization focused on housing and disseminating rural health related resources, including the Rural Suicide Prevention Toolkit. The seven-module toolkit compiles promising and evidence-based models and resources to support organizations implementing rural suicide prevention efforts.
The CDC, through publications, data and resources on its website, also provides technical direction and support for suicide prevention efforts, including rural-focused prevention. In a 2018 policy brief, the CDC identified four policy options and strategy areas that can be adapted for rural suicide prevention and could address specific factors and challenges unique to rural suicide risk and prevention:
- Improve Access to Mental and Behavioral Health Services: Because nearly half of all people who die by suicide encounter a primary care provider in the preceding month, integrating behavioral health services and screening into primary care may improve identification of at-risk individuals. Access to telebehavioral health services also may help reduce barriers to care.
- Reduce Stigma in Communities: Cultural values of individualism, stoicism and other rural social norms may increase stigma for mental health care seeking behavior in rural communities. By reducing this stigma, rural communities may support greater behavioral health service utilization.
- Increase Connectedness with Peer Norm Programs: Peer norm programs work with peer leaders, often in school settings, to increase connectedness, shift norms and make protective factors (supportive provider relationships, coping skills, connections to family and friends) more common.
- Work with Communities to Reduce the Risks for Suicide: The time between deciding to engage in suicide and attempting can be as short as 5‒10 minutes. Reducing easy and immediate access to lethal means, such as firearms or poison, may decrease suicide risk.