Suicide is one of the 10 leading causes of death in the United States, according to a November 2021 report from the National Center for Health Statistics (NCHS). The suicide rate increased 35% between 1999 and 2018, then dropped by 3% in 2019 and, according to NCHS provisional data, by another 2% in 2020. But despite this more positive trend overall, the gap between suicide rates in rural and urban areas has grown.

Figure. Maria Vega, a member of Montana's Fort Peck Assiniboine and Sioux Tribes, was jailed in 2015 after a suicide attempt. She is now part of a group of tribal members, academics, and policy experts proposing alternatives to the tribal policy of treating attempted suicide as a crime. Photo by Sara Reardon / Kaiser Health News.

According to an article from the Centers for Disease Control and Prevention (CDC) in the March 17, 2017, Morbidity and Mortality Weekly Report, suicide is more common in rural settings than in populous urban areas. Such geographic disparities "might reflect suicide risk factors known to be prevalent in less urban areas," the CDC reported, "such as limited access to mental health care, social isolation, and the opioid overdose epidemic, because opioid misuse is associated with increased risk for suicide."

The access problems are exacerbated by great need in rural areas. To cope with a critical shortage of qualified mental health care workers and facilities, the Fort Peck Assiniboine and Sioux Tribes in northeastern Montana created an "aggravated disorderly conduct" misdemeanor charge under which police officers can arrest tribal members deemed to be a risk to themselves or others. The detainees are put in a cell and observed-sometimes for days-until a mental health specialist is available.

The tribes enacted this extreme measure in 2010 to combat a wave of suicides and to compensate for woefully inadequate mental health resources. And even though the Fort Peck tribes now have funds to hire four additional mental health care specialists, it has been a struggle to find qualified people willing to live in the remote region.

A similar situation exists in rural Alabama, according to Monika Wedgeworth, an associate professor at the University of Alabama Capstone College of Nursing in Tuscaloosa, whose research interests include behavioral health care systems. "The National Alliance on Mental Illness gave Alabama a grade of D for its delivery of mental health care, and it has lower access to crisis care and psychiatrists per capita than almost any other state," she told AJN.

Privacy concerns could be a factor, according to Wedgeworth. "In rural areas, people may choose not to seek care at standalone mental health providers due to small town mentality that everyone knows everyone else," she said. To address this, Alabama is working to integrate behavioral health care into primary care practice. Such a system could both decrease stigma and increase holistic care while providing a one-stop care site for patients experiencing a mental health crisis.-Jennifer Huber, PhD