Overall Suicide Rates for Urban and Rural Counties in Pennsylvania, 1990-2018 (Source: Center for Rural Pennsylvania )

According to a study done by the Center for Rural Pennsylvania between 1999 and 2018, suicide rates across the state significantly increased. In 2018, the researchers said, the suicide rate in rural areas of the state was 25% higher than in urban areas.

While the study of suicides showed that the rate is higher in rural areas, those numbers may be even higher still, researchers said.

While the study didn’t specifically address the causes of the discrepancy in suicide rates in urban and rural areas, it did look at some of the indicators of higher suicide rates.

Higher numbers of handgun sales per 1,000 residents, lower levels of education, lower incomes, larger populations over age 65, and higher levels of unemployment all correlate with higher county suicide rates, the study found.

“In terms of our particular report, we are not able to deduce exactly why those rates have been increasing,” said Dr. Daniel Mallinson, one of the study’s authors. “But others whose work has looked at that…they've been able to gather some quantitative evidence on that. For instance, there's been a rise of deaths of despair, particularly in rural areas in the US, and not just in suicides but also in overdoses and alcohol-related deaths.”

The researchers connected these deaths of despair to the loss of quality of life and less economic opportunities, which have had “substantial impacts on people's lives directly and on people's resources but it also has damaged or undermined communities and families.”

Beyond the quality of life issues, according to the National Advisory Committee on Rural Health and Human Services, rural areas also tend to be at higher risk due to limits in the “accessibility, availability, and acceptability of mental health care services.”

Rural counties tend to have smaller ratios of mental health providers per capita. For instance, in Sullivan County, Pennsylvania, there are only 16 mental health providers per every 100,000 people, according to the Pennsylvania Department of Health. Compare that to Montgomery County, Pennsylvania, with 333 mental health providers per 100,000. And 23 of the 24 Health Professional Shortage Areas in Pennsylvania, identified by the U.S. Health Resources and Services Administration as areas that have a shortage of healthcare professionals, are rural areas of the state.

Drug overdoses, deaths due to alcohol-related illnesses and suicides are all termed “deaths of despair,” Mallinson said. As we’re seeing increases in drug use, we’re also seeing increases in suicide, he said. According to economists Anne Case and Angus Deaton, he said, those deaths of despair in rural America are the result of changing economic and social forces that have left these areas behind.

Bu the suicide numbers could be even higher, he said.

“We commonly assume that suicide rates are actually higher than what the reported rate is and it's because of those overdose deaths,” he said. “They will only be marked as suicide if there was a note left or some other clear indicator that the overdose was intentional… If there’s no extra evidence to support that though, it doesn’t get marked as a suicide on a death certificate.”

The rise in factors contributing to suicide are highly concerning, the report said. Rates of depression tripled during the pandemic, while firearm sales grew, social isolation became acute and emergency room visits for suicidal ideation , or thoughts of commiting suicide, increased.

According to the report, some researchers predict that we could see between 10,000 and 100,000 more suicides and deaths of despair over the next decade due to the pandemic. During the summer of 2020, the CDC reported that suicide rates were increasing. However, as the year ended, the rates seemed to drop, Mallinson said.

“That doesn't mean they went down everywhere,” he said. “That's the national rate. So, there may be places where they went up. Overdoses went up during Covid. Suicide-related ER visits for young female adults went up last year. So the Covid picture is definitely complex and it's still emerging…And we’re still seeing the emerging information about young adults. We’re still learning how deep that impact was from closing schools and kids being home for a year.”

Reports emerged during the pandemic, the report said, that remote learning was taking a toll on students. Clark County, Nevada schools re-opened after 18 students took their lives between March and December 2020 – twice the rate of the previous year.

Most suicide prevention starts in schools when mental health issues typically first emerge. The report found that rural school districts found it harder to continue providing services during the pandemic, than their urban counterparts did.

To address the rural/urban suicide gap, Mallinson said, rural communities need more funding and more resources to provide prevention programs.

“In a privatized healthcare system, like what we have in a lot of rural counties, there’s been a lot of healthcare consolidation,” he said. “And consolidation has brought closures. Those closures tend to be in rural areas. So, (residents in rural communities) are in a situation where if they need care, it’s even further away.”

Additionally, he said, once those programs are in place, they need to be evaluated on how well they work. Many of the counties Mallinson worked with had no evaluation program in place, and those that did fell short of a proper program evaluation, having instead run research on satisfaction with the program.

““That’s very different from real program evaluation,” he said. “Of course, program evaluation is hard and program evaluation can be expensive, so it's another resource issue.”

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