Evaluation of the Better Todays/Better Tomorrows Youth Suicide Prevention Program: Increasing Mental Health Literacy in Rural Communities
IntroductionLiving in a rural area often has a negative impact on mental health outcomes, sometimes leading to higher rates of suicide (Kann et al. 2014) Indeed, states with large rural and frontier areas such as Idaho, Oregon, and Utah have the highest percentages of people experiencing mental illness in the United States (19 to 22 percent) compared to 14 to 17 percent in Texas, Illinois, and Florida (Substance Abuse and Mental Health Services Administration [SAMHSA] 2014c) This is particularly significant because high suicide rates are strongly associated with mental illness: more than 80 percent of people who die by suicide were also reported to have a documented mental illness (Harris Barraclough, 1997; Hawton, Saunders, Topiwala, Haw, 2013) The link between suicide and mental illness is exemplified in Idaho, where death by suicide is particularly high for adolescents, with a suicide rate of 18.4 per 100,000 as compared to an average of 12.3 per 100,000 for the United States (Idaho Department of Health and Welfare, 2014) Certain racial and ethnic subgroups are at higher risk for mental illness and suicide. The rate of suicide for Native Americans is 11.00 per 100,000 compared to 5.1 per 100,000 for African Americans (American Foundation for Suicide Prevention [AFSP] 2014).Research suggests that the prevalence of mental illness and death by suicide in rural areas may be related to limited mental health literacy. Mental health literacy refers to individuals' beliefs and knowledge about mental health and suicide, which can include their ability to identify risk factors, protective factors, and warning signs (Jorm et al. 1997) Another component of mental health literacy is the ability to seek mental health services. Help seeking behaviors may be compounded by recurring stigma, geographic isolation, and access to few service providers. People living with mental illnesses in rural communities are fully aware of public stigma about mental illness through stereotypes and mistreatment from others (Larson Corrigan, 2010) For instance, people often apply labels such as dangerous or lazy to people with mental illness, which may lead to social isolation (Alexander Link, 2003; Link Phelan, 2014) Frequently individuals are not perceived as ill unless they are unable to work or perform specific tasks (U.S. Health Resources and Services Administration [HRSA] 2006) This encourages those living with mental illnesses to attempt to hide what can seem to be a hidden disability and avoid seeking help.In a cyclical manner, public stigma leads to self stigma when people with mental health conditions or their families internalize the stigma expressed in the public sphere. Self stigma disrupts both self efficacy and self esteem (Link Phelan, 2014) The spiraling down process of social isolation due to self stigma may lead to suicidal thoughts (McCann, Lubman, Clark, 2012) This may explain how mental illness and suicidality are so strongly associated.Geographic isolation is another factor that is linked to mental health literacy and help seeking behaviors. States with primarily rural and frontier communities are characterized by geographical and social isolation, with six or fewer people per square mile in many areas (HRSA, n.d. Distance and rugged terrain may become barriers to care for community members who seek health resources, including education about topics such as mental health (HRSA, 2006) For example, in a town in north Idaho near the Canadian border, the itinerant mental health counselor visits the town one day a week. In another town, one family drives approximately two hours to services six months per year over snow covered roads (A. Kirkwood, personal communication, May 10, 2008) These examples illustrate that support for obtaining community based services and educational trainings is needed for rural communities.A lack of service providers is also linked to limited mental health literacy.