Death by suicide is a serious problem in the United States and rural communities are
disproportionally affected by these tragedies.
1
According to the National Vital Statistics System (NVSS), suicide rates in rural communities
have risen significantly over the past few decades.
1
The gap between the suicide rates in rural and urban communities is broadening and
suicide rates are increasing at a faster rate in rural communities than they are in
urban communities.
1
For example, between 2010 and 2015, the suicide rates per 100,000 population in nonmetropolitan/rural
counties increased by 7.1% compared to 1.6% in urban counties.
1
These findings may be explained by factors such as decreased access to mental health
resources, stigma, and economic stressors.
2
Importantly, social isolation is an ongoing concern in rural areas, worsens mental
health, and is a factor in suicide risk.
2
Accordingly, there is an increased emphasis on the need to build social supports or
connectedness among communities as a strategy to combat suicide.
2
Social connection has been described as “the variety of ways we can connect to others
socially – through physical, behavioral, social‐cognitive, and emotional channels.”
3
The term social connection is frequently used to describe the social integration that
may decrease the risk of suicide.
4
Of course, the term social connection has taken on new relevance and meaning in rural
America in the wake of the recent COVID‐19 pandemic. What was until recently seen
as a critical positive characteristic is suddenly described as a situation and a condition
to avoid. Landmark work conducted by Durkheim demonstrates that social connectedness
is a vital factor in emotional well‐being and societal stability.
5
This may be especially true in the face of a public health crisis where individuals
encounter enormous psychological stress whether due to physical illness, trauma, or
economic instability.
4
While these stressors are, of course, jarring for any population, these events may
only exacerbate what rural populations have been increasingly facing for many years:
namely, barriers to health care, inconveniences in the marketplace, and economic hardships.
6
Lack of access to mental health care may be compounded in rural settings in the face
of pandemics, which necessitate the re‐allocation of resources not only to more populated
areas, but also to the treatment of the medically ill. Rural areas experience structural
limitations such as poor Internet,
6
which may limit access to 21st century resources including telemental health, working
from home, and video conferencing with friends and family that are widely available
to urban dwellers. Existing difficulties in accessing public transportation and the
Internet
6
may be compounded by the current COVID‐19 pandemic, causing great challenges to addressing
health care needs and obtaining basic necessities. Finally, people living in rural
communities may be at greater risk for suicide during economic crises.
7
These findings argue that our attention to suicide risk in rural populations should
be further heightened (rather than diminished) in the context of the COVID‐19 pandemic.
The pandemic has the potential to create additional obstacles to care, further erode
mental health, and intensify suicide risk. Yet, one of the most paradoxical issues
created by this pandemic is the tension between society's call for “social distancing”
and the critical need for rural populations to take active steps to strengthen and
enhance their sense of social integration and social connectedness. In fact, groups
with greater social integration may fair better during times of crisis, including
pandemics.
8
These observations raise 2 important questions. First, is there a need to reframe
public health messaging to ensure that there is adequate attention to the physical
and mental well‐being of rural populations? Second, what (if any) interventions have
shown promise in promoting social connectedness in rural populations during a crisis
where people need to physically separate to prevent the spread of an infectious disease?
Does Public Health Messaging Matter When It Comes to Suicide Prevention in Rural Communities?
Over the past few months, public health officials, lawmakers, and the media have rapidly
adopted the terms “social distancing,” “self‐quarantine,” and “isolation” in order
to combat the spread of COVID‐19. Naturally, some physical separation of people is
required to protect the common good, and yet “social connection” is essential to promote
health and in particular, prevent suicide.
4
How do we reconcile these 2 equally crucial behaviors without comprising the efficacy
of either in rural populations? More importantly, is our use of specific terms protecting
the physical and mental health of rural America? While the term “social distancing”
is intended to ensure that members of society avoid close physical contact with others,
the term can induce a strong sense of social disconnection at all costs. This is reiterated
by related behavioral measures (eg, legal fines, possible social ostracization) that
are now tied to this term in order to ensure the health of the public.
9
,
10
Notably, “social distancing” is a term that historically has been closely tied to
mental health stigma and prejudice.
11
In addition, greater “social distancing” has been associated with less empathy.
12
These factors, in turn, are important contributors to an individual's risk for death
by suicide.
13
,
14
Of course, an argument can be made that society at large is really interested in ensuring
that individuals maintain physical or bodily separation from others in order to mitigate
the risk for the spread of illness. Perhaps, public health messaging should speak
more directly to rural communities about the key need for physical separation or bodily
boundaries during this time of crisis, while at the same time heavily emphasizing
the key need to pursue emotional and social connections with others in order to preserve
their mental well‐being. In fact, while rural communities may be learning about how
viruses spread and their associated harms through the media and government sources,
these communities are receiving comparably far less education around the importance
of taking steps to mitigate the serious psychological consequences that can follow
in the wake of a pandemic. Indeed, the term “social distancing” may highlight the
peer as the source of the threat, when the real threat is the virus. We propose the
term “physical separation, while maintaining social connection.”
What Can Be Done to Bolster Connectedness and Prevent Suicide in Rural Communities
During a Pandemic?
Despite the potential for their vulnerabilities to be exacerbated by the COVID‐19
pandemic, rural communities have considerable resilience in times of stress and adversity.
15
In relation to suicide risk, the tendency for rural communities to have strong loyalty
to family and a sense of solidarity with their community may be protective.
2
It has long been understood that successful interventions to help communities recover
from disasters rely on recognizing and building upon the resiliency inherent in communities.
16
Similarly, rural communities may benefit from suicide prevention strategies that promote
connectedness.
17
Therefore, it is possible that focusing on the unique features of rural populations
that confer resilience could help in designing interventions to mitigate suicide risk
in the context of the COVID‐19 pandemic.
In the case of pandemics in particular, aspects of rural communities that put them
at risk could also be tapped into for developing resilience during a pandemic and
quarantine. Studies of past pandemics have highlighted both the potential for resiliency
and pathological responses.
18
For instance, a study conducted during the Severe Acute Respiratory Syndrome (SARS)
pandemic in Hong Kong found that many surveyed individuals reported greater social
support, a better lifestyle, and more mental health awareness during versus before
the pandemic.
18
Several factors were thought to contribute, including having more time and the ability
to reassess priorities.
18
Psychological resilience
19
and community‐connectedness
8
may also be protective during a disaster or public health crisis. Chan and associates
20
also tested a strength‐focused intervention during the SARS pandemic, "The Strength‐Focused
and Meaning‐Oriented Approach to Resilience and Transformation (SMART)," with a group
of adolescents and people with chronic disease. The intervention emphasized resilience
and transformation in the aftermath of panic and quarantine. The intervention targeted
awareness, strength, and meaning‐making in the mind, body, and spirit. Among adolescents
exposed to the SMART intervention, there was a significant decrease in perceived social
disintegration and a significant gain in self‐mastery and social responsibility or
engagement.
In addition to focusing on resilience and promoting participatory research to discover
the needs of rural communities, it may be vital to create interventions that are more
collective in nature, rather than focused on the individual. This might be especially
important given that rural communities may struggle more with stigma and be less likely
to seek treatment. A focus on community strength rather than individual problems may
be more palatable and ameliorative for people in rural communities.
The COVID‐19 pandemic has highlighted the tension between the need for physical distancing
and the necessity for social connection. Being embedded in social relationships is
particularly pressing for rural populations with their higher risk for suicide, and
in the midst of this pandemic. The coalescence of risk and protective factors inherent
in the rural community make a good case for turning more pointedly toward interventions
that promote social connection. This directly addresses the call to make social connection
a more prominent concern for health policy.
3