Suicide: Focus on Prevention of Rural Suicides

As the nation’s healthcare spotlight focuses on September as National Suicide Prevention Month, rural health providers and educators are taking stock of tools and practices that can help reduce the suicide rate – a rate the Centers for Disease Control and Prevention (CDC) reports as the 10th-leading cause of death for Americans.  It’s also within the top five causes of death for Americans between the ages of 10-54.

Suicide rates among rural Americans are alarming: such deaths have increased by more than 40 percent in 16 years. More troubling is that 88 percent of such patients who died by suicide had contact with their primary care provider (PCP) at some point during the year prior to their death, and more than 66 percent had contact with their PCP during the month prior to their death.

Rural Relevancy

More than 65 percent of the approximately 65 million rural Americans receive mental healthcare from their PCP.

With a growing shortage of mental and behavioral health providers, in rural areas a PCP is the often the only care provider available. There is also less stigma in seeking care in a doctor’s office than in a “mental health” or “behavioral health” setting. Also, since many use the emergency room as their first point of entry, they might not “self-identify” with mental health symptoms but rather seek care for other physical symptoms that have underlying mental health causes. 

Contributing and Connected Factors

Among those factors contributing to suicides among the rural population are:

  • Geographic and social isolation – access/proximity to care
  • Limited access to mental health/behavioral healthcare services and other specialists
  • The heroin and opioid overdose epidemic – drug misuse is associated with increased risk for suicide
  • Overall health issues such as chronic back pain, cancers, sleep disorders, migraines, and dementia
  • Access to firearms
  • Finances
  • Trauma (emotional and physical)

For all that PCPs are called upon to perform for patients, they often receive little support, training, or guidance to prepare them for interventions and care for suicidal patients.

Given the aforementioned, PCPs, physician assistants, and nurses need to be given tools to better help them identify and address critical needs of suicide patients; they need education and training, as well as information regarding best practices in suicide prevention and risk detection.

Among some of the tools and resources available to address suicide prevention, as well as treatments of care, are the following:

Suicide Prevention Toolkit for Rural Primary Care Practices

This Toolkit was developed by the Suicide Prevention Resource Center (SPRC) and the Western Interstate Commission of Higher Education (WICHE) Mental Health Program. The WICHE Center for Rural Mental Health Research was established in 2007 to develop and disseminate scientific knowledge for improving and/or increasing the quality, use, and outcomes of mental health in rural communities. It is one of seven rural research centers funded by the Federal Office of Rural Health Policy’s Health Resources and Services (HRSA).

The current Toolkit includes components from the original Toolkit and others that have been added. They now include the following:

 Core Start-Up Components:

  • Introductory letter
  • Quick setup
  • Primer (an educational overview of best practices in suicide prevention)
  • Resource list

Mental Health Partnerships:

  • Outreach letter
  • SAFE-T Card

Patient Manager Tools:

  • Primary care pocket cards
  • Safety planning tools
  • Crisis support planning tools
  • Tracking log
  • Primary care practice model
  • Safety planning card
  • Catalog of posters/brochures

Other resources for rural healthcare providers and educators include the following:

  1. “Suicide Safe:” This is a suicide-prevention mobile learning tool that can help providers integrate suicide prevention strategies into their practices and reduce suicide risk among their patients. The Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) free app is available for Android and iOS operating systems.
  2. “Suicide Prevention: Not Another Life to Lose” provides insights from professionals, a plethora of community resources, and inspiring, poignant stories of survival, resiliency, and courage.
  3. Depression Toolkit for Primary Care Clinicians: The Patient Health (PHQ) Adolescent Toolkit is designed to help PCP teams effectively assess, treat, and monitor depression in adolescents with suicide risk behaviors.
  4. Teen Screen Primary Care Program: This program offers support to healthcare professionals working to implement mental health screenings for adolescent patients who either have depression or are at risk for suicide. These screenings are recommended by the American Academy of Pediatrics (AAP) and the U.S. Preventive Services Task Force.
  5. The Rural Assistance Center provides resources and tools to address suicide in rural and frontier areas of the nation, where suicide is the second-leading cause of death.
  6. The Suicide Prevention Resource Center’s American Indian/Alaskan Natives website provides professionals with tools to support suicide prevention and mental health promotion.
  7. The Safety Plan Treatment to Reduce Suicide Risk for Veterans is a manual that provides safety planning and clinical intervention that can be leveraged as a valuable adjunct to risk assessment. The tool can be used to care for veterans who have either made a suicide attempt, have suicidal thoughts (referred to as ideation), who have been determined to be at high risk for suicide, or those who have psychiatric disorders.
  8. Mental Health First Aid for community members, this is a public health education program that helps the public identify, understand, and respond to signs of mental illness and substance use disorders. This site and related resources are managed and information disseminated by the National Council for Community Behavioral Healthcare, the Missouri Department of Mental Health, and Maryland Department of Health and Mental Hygiene.
  9. The CDC offers “Promoting Individual, Family, and Community Connectedness to Prevent Suicidal Behavior.” The program describes the CDC’s five-year vision to focus on preventing fatal and non-fatal suicidal behavior. As noted, the CDC’s strategic aim is to prevent suicidal behavior by buildings and strengthening connectedness or social bonds within and among persons, families, and communities.

The Rural Preparedness Summit: “Rural and Ready”

Much like hospitals and other healthcare organizations that have emergency preparedness plans, the Nevada Office of Suicide Prevention and Nevada Army National Guard Chaplain Corps have been partnering to present “Safe TALK” training. Known as “Rural and Ready,” a group of social workers, community health professionals, and first responders from Northern Nevada strategically meet to gain education on prevention programs and to find ways to collaborate with other organizations to make the rural communities they serve safer.

Veteran’s Telehealth: To the Moon and Back

Female veterans are at greater risk for suicide than the population at large, with a rate 2.5 times higher than that of female civilians. As it relates to male veterans, the risk is 19 percent higher.  Finally, roughly 56 percent of most military suicides occur among older veterans ages 50 and older. Within another context, 44 percent of veterans from Iraq and Afghanistan return to rural environments. Care delivered by telehealth and telepsychiatry appear to be  closing the disparity gap of care and access. In one year, veteran telehealth services saved patients 826,290 miles – the equivalent of three and one-half trips to the moon – and an estimated $161,126 in gas.

The Promise of the ECHO Model for Suicide Prevention

One of the biggest milestones in federal support of suicide prevention is Congress’s passing of the bipartisan, bicameral Expanding Capacity for Health Outcomes (ECHO) Act. Project ECHO provides professional development services to remote and rural health providers nationwide. The new legislation calls for pairing academic specialists with PCPs through virtual clinics that have been designed to mentor providers while also addressing behavioral and public health needs. In doing so, Project ECHO also aims to reduce providers’ sense of isolation via a network of support. The ECHO Act is a successful model that will help better serve patients in areas such as suicide prevention, pain management, and addiction. 

Rural Veterans and Precision Care

Also prevalent in the area of suicide prevention is the identification of depression in the form of post- traumatic stress disorder (PTSD). Treatment often is found in pharmacogenetics that allow veterans to experience the benefits of correct dosage the first time and knowing how quickly or slowly a medication metabolizes in the body. 

Upcoming Grants for Suicide Prevention

There are two grant opportunities scheduled to become available in the fall include the following:

Indian Health Service Zero Suicide Initiative grants are available to implement the “Zero Suicide” approach in Native American country, with the goal of improving the system of care for those at risk for suicide by implementing a comprehensive, culturally informed, multi-setting approach to suicide prevention in American Indian health systems.

Geographic coverage: The nationwide application deadline is Oct 12, 2017. The sponsor is the Indian Health Service Division of Behavioral Health.

Addressing Suicide Research Gaps: Understanding Mortality Outcomes (R01) research grants are available to link data from healthcare system records to mortality data in order to obtain an accurate understanding of the risk factors for, and the burden of, suicide among individuals seen in structured healthcare settings. Priority is given to studies of suicide risk and mortality in health disparity populations, including racial/ethnic minorities, socioeconomically disadvantaged populations, underserved rural populations, and sexual/gender minorities.

Geographic coverage is nationwide. The application deadline is  Nov. 2, 2017; the sponsors are the National Center for Complementary and Integrative Health, National Institute of Mental Health, National Institute on Drug Abuse, National Institute on Minority Health and Health Disparities, National Institutes of Health, and U.S. Department of Health and Human Services.

Timeless Focus

Back in 2015 there was a meeting convened byA Community of Practice” via the Suicide Prevention Resource Center. Their recommendations seem especially applicable in 2017 as part of today’s contemporary rural healthcare focus in improving suicide prevention in rural areas. These recommendations included:

  • Train primary care professionals to screen for suicide risk and connect patients to referral resources;
  • Strengthen capacity of crisis centers to link to appropriate local resources;
  • Use federal, state, or local resources to incentivize mental health professionals to work in rural areas;
  • Target suicide prevention programming to community or population needs by collaborating with state epidemiologists, universities, and crisis centers to access local data on suicide deaths, attempts, and risk and protective factors; and
  • Establish protocols on crisis response for the local community, including alternatives for transportation to hospitals and emergency services or alternate assessment procedures.

Going the Distance

We have a long way to go, but we are grateful to the services and professions that provide our rural communities with the care, attention, and focus needed to make each patient healthy in mind and body. We need to reinforce patient-centered care from a 360-degree community focus that also includes more partnerships with public health departments.

Every 15 minutes, someone in the U.S takes his or her own life, and for every suicide it has been noted there are as many as 25 attempted suicides. No person or family or community should know this tragedy. Let’s bring suicide out of the dark and into the light, because suicide and those affected by it should never be isolated.


Janelle Ali-Dinar, PhD

Janelle Ali-Dinar, PhD is a rural healthcare expert and advocate with more than 15 years of healthcare executive experience in many key areas addressing critical access hospitals (CAHs), rural health clinics (RHCs), physicians, and patients. Dr. Ali-Dinar is a sought-after speaker on Capitol Hill. A former hospital CEO and regional rural strategy executive, Janelle is also a past National Rural Health Association rural fellow, Rural Congress member, and Nebraska Rural Health Association president. She is currently the Nebraska DHHS chair of The Office of Minority Health Statewide Council, addressing needs of rural, public, minority, tribal, and refugee health, and she serves on the Regional Health Equity Region VII council as co-chair of Rural Health and Partnerships. Janelle holds a master’s degree and doctorate in communications and is a recent graduate in public health leadership. Janelle is currently the vice president of rural health for MyGenetx and is a member of the RACmonitor editorial board.

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