Overcoming Barriers to Effective Suicide Prevention in Rural Communities

The potential suicide of a student is a serious concern for many K–12 educators and administrators. Results from the 2019 Youth Risk Behavior Survey indicate that 18.8% of teens seriously considered suicide, 8.9% reported at least one suicide attempt, and 2.5% said that they made an attempt that required medical treatment during the previous 12 months (Ivey-Stephenson et al., 2020). As discussed else-where in this volume, the epidemiological trends of youth depression, hopelessness, suicidal thoughts, and suicide deaths are sobering (see Bridge et al., this volume). Identifying and treating youth suicidal thoughts and behaviors as early as possible is optimal; however, reaching youth who are at risk presents logistical and practical challenges in rural communities. This makes serving youth where they spend the majority of their time, in the school context, particularly important. However, most schools are already overburdened, and therefore suicide prevention efforts in schools will only succeed if community partners are also committed to reducing existing burdens placed on teachers, counselors, social workers, and administrators, which includes minimizing the negative impact on instruction time.

In addition to integrated school mental health models, technology represents a way to overcome traditional barriers in rural communities. Over the past few decades, there have been significant strides in deploying tele-behavioral health (TBH) solutions for mental health issues with outcomes that are often equivalent to traditional in-person care. Most youth are well versed in using digital platforms for school-work, creative expression, and social engagement, making them “digital natives” who readily accept and adopt evolving technologies (Nesi, 2020). Using digital platforms to deliver mental health care is therefore a feasible and acceptable method of service provision for most youth. Despite the upside of such approaches and the emerging evidence base, there have been barriers in adopting TBH. These include inflexibility of regulating bodies, interstate variability in legal requirements for privacy and security, licensure guidelines that restrict reimbursement, insurance coverage limitations, and an inadequately trained TBH workforce. A silver lining of the COVID-19 pandemic is that the process of pivoting to remote practice methods has accelerated dramatically and readiness to adopt these strategies has likely increased.

One of the persisting barriers to TBH is inconsistent access to broadband connectivity and high-speed data-enabled phone services in rural communities. Even when there is adequate connectivity, socio-economic disparities that are prominent in rural communities have exacerbated existing access barriers. It can be challenging for families to afford to purchase the necessary equipment for TBH, such as smart phones or camera-equipped laptops (Benda et al., 2020). Overcoming access and acceptability barriers to suicide prevention in rural communities ideally involves the merger of the two primary innovations highlighted in this chapter, that is, coupling TBH and school mental health partnerships while seeking funding from local companies and mental health boards as well as small grants from school boards. Such funding can help to offset costs of technological supports (e.g., remote hot spots) and the clinical labor necessary to implement effective suicide prevention programming (Michael, 2020).

There are a number of well-documented barriers when planning and implementing suicide prevention strategies in rural communities. However, school mental health partnerships and TBH innovations represent two approaches that have shown considerable promise in overcoming known impediments to service provision and the prevention of youth suicide in remote settings. Clinicians, program developers, educators, policymakers, and researchers are encouraged to consider four specific recommendations when attempting to address these aforementioned barriers.

First, those interested in school mental health partnerships and telehealth solutions for suicide prevention in rural communities are strongly encouraged to include evidence-based, suicide-specific therapeutic assessments and management paradigms, such as CAMS, as a key feature of their programming. Second, developers and implementers should focus on promoting means reduction principles, including the consistent use of safety plans in their work with patients and families. Some states (e.g., North Carolina) have applied for and received federal funding through the CDC to provide and sustain CALM trainings for mental health clinicians and organizations statewide. Similarly, community agencies, K–12 schools, and health departments should consider partnering with local gun shops and community members invested in firearm safety, proper medication disposal, and safe storage programs to reduce suicide death overall (see Harvard’s Means Matter website for a review: https://www.hsph.harvard.edu/means-matter/gun-shop-project/). Third, K–12 partners in rural communities should consider the specific guidance by Schorr et al. (2017) and implement already established evidence-based suicide prevention programs in rural schools. The two programs that have the strongest evidence are Signs of Suicide (SOS; Aseltine et al., 2007) and Lifelines: A Comprehensive Suicide Awareness and Responsiveness Program for Teens (Underwood & Kalafat, 2009). Schorr et al. (2017) also provide a considerable amount of guidance for implementing effective suicide prevention programs across the multitiered systems of support (MTSS) framework in the context of rural schools. Lastly, those interested in scaling up TBH solutions should apply for federal grants like the Distance Learning and Telemedicine (DLT) Program offered by US Department of Agriculture and consider implementing a suicide-specific program such as CAMS, especially in light of recent innovations developed during the COVID-19 pandemic (e.g., Jobes et al., 2020). Investments in rural communities will help curb youth suicide rates in settings, but understanding how to navigate their specific barriers and opportunities is critical.