The high rates of suicide among rural Veterans may be linked to an interaction between attitudinal barriers to care (e.g., stigma) and structural barriers (e.g., geographic isolation, transportation) with a health care system that has fewer resources and training to effectively identify, treat, and manage suicidal patients.
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Suicide Risk Management
Rural Provider PTSD Toolkit
Suicide Risk Management
What creates additional risk?
In general, suicide risk is greater in rural compared to urban areas.38-40 Evidence also suggests that suicide rates are increasing more rapidly in rural settings. Importantly, Veterans are at higher risk for death by suicide than the general population, regardless of location.38 These trends highlight the critical importance of suicide risk management among rural Veterans, who are at increased risk of death by suicide relative to non-Veteran rural residents and their urban Veteran counterparts.9
Attitudinal barriers
Structural barriers
Attitudinal barriers
These barriers include stigma, lack of perceived need, and desire to handle problems by oneself. Attitudinal barriers that impede access to mental health treatment may be higher in rural areas.41 Greater stigma towards suicide, mental illness, and help seeking; increased geographic and social isolation; greater access to firearms; and economic and social fragmentation have all been cited as risk factors for suicide associated with rurality.39
Structural barriers
These barriers include financial means, transportation, and availability. An abundance of literature demonstrates that rural communities have fewer mental health resources and less knowledge and training for suicide prevention and treatment among health care professionals.42 Rural Veterans are less likely than urban Veterans to access mental health services, yet VA-enrolled Veterans living in rural areas report lower mental health-related quality of life than their urban and suburban counterparts.3,43,44 Rural Veterans with a mental health diagnosis experienced greater disease burden and health care costs than their urban counterparts.45
Steps in Suicide Risk Management
Suicide risk management must take into account the multiple intersecting risks presented by rurality--in particular, cultural attitudes around help seeking, access to firearms and cultural norms regarding firearm ownership and use, barriers to treatment (such as transportation), and the availability of care professionals with expertise in the treatment and management of suicidality.Click to reveal more information about the process of suicide risk management.
1. Effective suicide risk management strategies start with a comprehensive assessment of a Veteran's level of suicide risk.
- Include information about current and recent thoughts of suicide (including frequency, intensity, and nature).
- Address intent to act on the thoughts.
- Inquire if the Veteran has a method, plan and the means to carry out intent.
- Assess for history of suicide attempts and preparatory behavior (e.g., obtaining lethal means, writing a suicide note, giving items away), particularly any recent steps taken.
- Ask about risk and protective factors as well as the Veteran's specific warning signs indicating a suicidal crisis.
3. Information is then integrated to determine Veteran's level of risk.46,47 Risk management efforts focus on helping the Veteran cope with factors elevating risk and enhancing factors that reduce risk.
- Strategies to manage chronic risk for suicide may overlap with acute risk management strategies and will likely also include evidence-based strategies for improving coping skills and managing psychiatric symptoms identified to be contributing to risk. Using information from the risk assessment and risk level determination, a provider will determine the level of care (e.g., outpatient, inpatient) needed.48
- Some factors to consider in this determination are the Veteran's:
- Willingness to create and follow a safety plan
- Access to lethal means
- Availability of a support system to help monitor acute risk
- VA's Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) developed a clinical tool to support providers in stratifying acute and chronic risk, this can be accessed on the MIRECC website.
- Risk management strategies are tailored to the individual Veteran and the factors that are currently elevating risk (e.g., psychiatric symptoms, psychosocial stressors). In addition, familiarize yourself with two essential general strategies: safety planning and lethal means safety counseling.
- The safety plan is a brief clinical intervention that consists of a hierarchical list of coping strategies that can be utilized prior to or during a suicidal crisis.49
- Lethal means safety counseling involves a collaborative discussion with the Veteran, friends, family, and others to facilitate limiting access to lethal means during-high risk periods. Learn more about this training and lethal means safety on the MIRECC website.
Working with Veterans at risk for suicide can feel stressful and overwhelming at times. There are resources to support providers who see Veterans, both within and outside VA.
