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Suicides: Rural rates on the rise: Access to care an important resource for prevention

BEMIDJI—Rural Americans killed themselves at a higher rate than their more urban counterparts, new research suggests.

Suicide rates have steadily gone up across Minnesota and the U.S. over the past 15-20 years, but a mid-March report from the Centers for Disease Control and Prevention concludes that less populous and less metropolitan counties saw some of the highest annual increases during that time.

"Rural areas are at greater risk because there are barriers to service, and transportation is a huge issue around here," said Stephanie Downey, the former suicide prevention coordinator at Bemidji's Evergreen Youth and Family Services who now works for the Minnesota Department of Health. The CDC's researchers also pointed to social isolation and the growing misuse of opioids as other possible factors.

"Micropolitan" counties—like Beltrami, which has an urban cluster of 10,000 to 50,000 people but fewer than 100,000 people in total—had, on average, about 14 suicides per 100,000 people in 1999, the CDC said, and nearly 20 in 2015. The suicide rates in "large central metro" and "large fringe metro" counties rose then, too, but still haven't equalled the figures reported in the least urban ones nearly 20 years ago.

The rural-urban suicide gap widened after 2007-2008, the CDC reported, and researchers there speculated that the economic recession—which affected rural areas more than urban ones—might have played a role.

"We live in an area of the state where we're taught to be independent, solve our problems on our own, take care of ourselves, but the reality is that's really difficult for one person to do," Downey said. "You need a net of supports that includes a lot of different people and different healthy activities."

The suicide rate in Minnesota is generally lower than the national average, but has been climbing nonetheless. The state's Department of Health reported 726 suicides statewide in 2015, or 13.1 out of every 100,000 Minnesotans. That's the highest rate since 1986, according to the department.

The Department of Health reported 52 total suicides in Beltrami County between 2010 and 2015; 23 in Cass; six in Clearwater; and 21 in Hubbard County.

Who? Why?

Men kill themselves at a rate 3-5 times higher than women, and Minnesota's male suicide rate climbed to 21.4 people per 100,000 in 2015, according to data from the department of health, and 20- to 44-year old males are particularly at risk.

Downey said she doesn't know why that demographic's suicide rate has spiked, but major life transitions—like finishing college and moving into the workforce—and economic stress can come into play.

"A middle-aged male, if there's hard economic times, maybe they're not feeling like they can provide for their family," she said. "In some times for some people, if they don't have the right kind of coping tools in their net, those events can trigger depression for a person, and sometimes with depression comes suicidal thinking."

The suicide rate for women has steadily climbed, too, but was still only 5.9 women per 100,000 in 2015.

American Indians commit suicide at a higher rate than any other racial demographic, according to CDC data.

"It's all about protective factors and risk factors," said Gary Russell, who directs Evergreen's shelter program, which serves youth ages 9-17 and can conduct free coaching sessions with families. Untreated mental health issues—such as depression—are a significant risk factor, Russell explained. So are aggression, substance abuse and trauma.

"You look at certain communities that are steeped in poverty, a lot of trauma, a lot of addiction. Unfortunately, that's describing life on certain parts of the reservations," Russell said. "Folks are just dealing with a whole lot more, have more risk factors and fewer protective factors."

How? And how to stop it

"When somebody completes a suicide, our first question is always 'why?' Why did this happen? Why did they do this?" Kara Bennett, who directs the suicide prevention program at the National Alliance on Mental Illness' Minnesota branch, told attendees at a March 23 public health conference in Bemidji "And we're really starting to ask the question 'how?' much more frequently because if we understand how someone completed suicide that gives us some really good information that can prevent that sort of death in the future."

The suicide rate in Britain dropped by one-third after the country started using nontoxic domestic gas, and Sri Lanka's was cut in half after the government there placed restrictions on toxic pesticides, Bennett said. The Israeli Defense Force saw a 40 percent drop in suicides once soldiers were barred from taking their firearms home with them on weekends, she added.

"What we know from these examples is that people use what's available," Bennett said, adding that people who attempt to kill themselves typically do not have a "plan b" method. "If we put time and space between the person at risk and the means to carry out some ideation, we can help save those lives."

The "acute" phase of a suicide crisis is often brief, Bennett explained. Many people who survive suicide attempts, she said, reported that they tried to kill themselves within five minutes of deciding to do so. About half reported an attempt within an hour of their decision, but only 13 percent said they waited a day or more.

Youth suicides in particular can be impulsive decisions, Bennett said, because adolescent brains have not fully developed the part that considers long-range consequences.

Alcohol is also a factor because it's a depressant that lowers inhibitions.

Bennett recommended securing or removing firearms; medication; knives and other sharp objects; ropes; and even car keys from a home with a suicidal person. She also discouraged purchasing over-the-counter medication in bulk, and suggested that families only have ready access to the medication they need for a given day.

The presence of a gun in the home can double the chance of youth suicide, she said, and locking one up might not be enough because kids often know their parents' passwords or where guns or keys are hidden.

"It's hard to safeguard against everything, but do the best that you can," Bennett said. "Ultimately, we want to slow someone down. We don't want it to be easy for them to get to something."

Some police departments and gun clubs can store firearms if necessary, Bennett said. Staff at the Bemidji Police Department said that they can hold firearms for a short while if they respond to a suicide call involving one, but can't store them long-term—maybe a month at most.

Beltrami County itself doesn't offer any direct suicide prevention services, but does address the peripheral issues that can lead to it, like chemical dependency.

The Upper Mississippi Mental Health Center has offices in Park Rapids and Bemidji, and runs a mobile "crisis response team" that offers year-round, round-the-clock responses to people who call their hotline: (800) 422-0045.

The "TXT4Life" program offers confidential counseling and help to anyone who texts "LIFE" to 61222.

Mental health issues and suicide can have a stigma attached to them, which can sometimes make friends and loved ones—especially youth—feel like they're in a bind: do they report their friend and jeopardize their trust?

"There's a difference between reporting when it's in someone's best interest because you care about them and squealing just to try to get them in trouble," Russell said. "If you're going to be a good friend, there's certain times when you do need to report, even if you think your friend might feel a little betrayed or get mad at you."

Evergreen staff try to teach kids the warning signs of depression and suicidal ideation, Russell said, and how to confront the "codes of silence" around mental illness.

"Don't be afraid to ask if you think someone's having suicidal thoughts," Russell said. "No one's ever killed themselves because someone bothered to ask if they were feeling that way."