Shortly after Izaiah Fiedler died by suicide in Tahlequah, a mental health clinic that his mother had hoped would work her son into its schedule called to offer an appointment.
The timing is not lost on Fiedler’s mother, Dru Teehee.
“Wait times are ridiculous,” Teehee said of the time it takes to get in to see a mental health professional.
Since her son’s suicide in 2017, Teehee has learned a lot about the topic, including how a medicine her son was taking at the time can impact one's mental health and how difficult it can be to obtain mental health services, especially in rural Oklahoma.
Teehee is not alone on the latter issue.
Experts say the need for more mental health services is greater in rural areas compared to urban areas.
It’s one reason why the suicide rate in rural areas is typically higher than in urban areas. That need has been especially acute during the COVID-19 pandemic.
Indeed, a Tulsa World analysis of state Medical Examiner's Office data found that suicides in Oklahoma rose nearly 10% from 2019 to 2020, with rural counties accounting for most of the increase.
The unofficial data provided by the M.E.'s Office and analyzed by the World found 875 suicides were recorded during 2020 in Oklahoma, compared to 801 documented during 2019.
The World analysis also found that rural suicides — those outside the Tulsa and Oklahoma City metropolitan areas — increased by 27% from 2019 to 2020, while counties within the two major metro areas saw a 2% decline during the same period.
State officials attribute the higher suicide rate in rural areas to a variety of forces, ranging from a relative scarcity of mental health availability, to the ability to physically access help, to rural residents being more isolated, especially during the COVID-19 pandemic.
Jessica Hawkins, senior director of prevention services with the Oklahoma Department of Mental Health and Substance Abuse Services, said the higher suicide rate in rural areas is not a new phenomena.
“Rural states and rural counties in general have been disproportionately impacted by suicide for a very long time now,” Hawkins said.
While not new, the trend is still concerning in Oklahoma due to its rural nature, she said.
“We have to be concerned and have resources in place to address it,” Hawkins said.
If rural Oklahoma was a state on its own, its 2020 suicide rate would be the third highest in the nation, compared to other states’ most recent figures.
A Tulsa World analysis found that only Wyoming and Montana have higher suicide rates than rural Oklahoma, where the latter’s 2020 suicide rate was 25.7 per 100,000 people.
The 2019 suicide rates in Montana and Wyoming, the most recent available, was 26.2 per 100,000 people in Montana and 29.6 per 100,000 people in Wyoming.
Nationally, the U.S. suicide rate was 13.9 per 100,000 population in 2019, while Oklahoma ranked seventh nationally in suicides at 20.6 per 100,000, according to the CDC.
Terri White, executive director of Mental Health Association Oklahoma, said the increase in suicides in rural Oklahoma from 2019 to 2020 reflects how the COVID-19 pandemic negatively affected suicide rates, especially in rural areas.
A number of barriers are to blame for higher suicide rates in rural parts of the state, she said.
“Rural residents, in general, are slightly more likely to experience mental health issues and are less likely to seek treatment for their conditions,” White said. “Also, transportation and a lack of financial resources can further decrease access to their mental health care. There also tends to be more stigma about mental illness in rural areas than in urban areas.”
White said rural women as a whole, and rural pregnant women in particular, are an example of how the population is at greater risk for behavioral health issues than women living in urban communities.
White said rates of severe mental illness, major depressive episodes, severe psychological distress, suicide and substance use among adolescents are higher in rural areas than in urban areas, citing a Rural Policy Health Institute study.
Mental health care access lacking
White said a lack mental health professionals in rural areas is another factor believed to be contributing to higher suicide rates.
“We need incentives to attract more mental health professionals to rural areas and to continue expanding the use of tele-mental health services,” she said. “The stigma of mental illness also keeps people from going into this field when they have to choose what their career's going to be. Because of these things, we end up with treatment gaps in the system.”
White cited a 2020 study by Mental Health American, which found that Oklahoma ranked No. 41 among states and the District of Columbia in the prevalence of mental illness and access to care.
White said there is one mental health provider for every 240 residents in Oklahoma, a figure that she said is oftentimes higher in rural areas.
A study by the Healthy Minds Policy Initiative, a Tulsa-based, nonpartisan mental health data and policy organization, found that mental health care access is lacking in rural areas.
Most rural residents in the state have no psychiatrist in their county, the study found.
Oklahoma has about 10.3 psychiatrists per 100,000 residents, about one-third of the recommended 30.3 psychiatrists per 100,000 residents, according to the study, released in 2020.
These shortages are being worsened by increased demand resulting from the COVID-19 pandemic and will be intensified as the state expands Medicaid, the study found.
Ashley Lincoln, Cherokee Nation Behavioral Health Administration Operations Manager, said urban areas generally have more mental health resources available and easier access to them.
“In rural areas, there are less mental health resources and larger challenges for those to be able to access what resources might be available,” Lincoln said. “A large majority of our clients struggle with finding consistent and reliable transportation to services. This is compounded by poverty, intergenerational trauma, and historical trauma that many people are battling.”
And while the use of telemedicine received a boost during the pandemic, Lincoln noted that many rural residents do not have reliable internet access or have a means to connect with a provider using digital interfaces.
The tribe has taken a number of steps to improve the mental health of its citizens.
Those steps include:
- Pushing out resources on every level. “On a community level we are working with Cherokee Nation communications to provide tips and resources you can access from home such as mindfulness activities, relaxation techniques, apps to help with anxiety, etc.,” Lincoln said.
- Use of federal grants. “We have several federal grants that are funding suicide prevention efforts,” Lincoln said. “The Zero Suicide grant works to screen every client for suicide in the 14-county reservation that comes into a Cherokee Nation facility. The family care managers on this grant follow-up with everyone who screens positive to offer them support and resources in their area.”
- Adolescent screening. “Cherokee Nation Behavioral Health also received the Garrett Lee Smith grant that focuses on screening for suicide in adolescents and providing them and their families access to needed care,” Lincoln said. “This grant also focuses on workforce development to train adults how to assess for suicidality and intervene when needed.”
Lincoln said their efforts have been encouraging thus far.
“We've found there has been an increase in access to care and in community collaboration,” Lincoln said. “There has been greater focus on mental health and addressing suicidality in our rural areas, which has led to a decrease in stigma associated with seeking out mental health services.”
Lincoln said the Cherokee Nation also has created programs for citizens to have internet access at home and in our more rural areas.
Risk factors affected by pandemic
Hawkins, with the ODMHSAS, agrees that the pandemic most likely played some part in the increase in suicides as it impacted several risk factors associated with suicide.
“Social connections, relationships, isolation, access to services, job loss, all of these things were worsened with the last year and half of the pandemic,” Hawkins said.
Fortunately, she said the state has launched several initiatives in recent years aimed at reducing the number of suicides.
“I actually think many of the actions we’ve been taking probably helped mitigate an even worse outcome perhaps in what we are seeing,” Hawkins said.
One of the new strategies includes the use of telemedicine to reach those unable to come in person for an appointment with a mental health provider.
The state has also pushed the use of the National Suicide Prevention Lifeline, a 24-hour service which provides crisis counseling.
“It is a critical element of our suicide prevention plan,” Hawkins said. “Making sure there is always someone to talk to in Oklahoma when in need.”
Hawkins said while the state already has strong children’s treatment programs used in schools, a new state law will further that progress.
Senate Bill 21, which took effect July 1, requires public school staff to be trained in suicide prevention by the ODMHSAS, Hawkins said.
Prior to the law change, an estimated 13,000 school staff received training when it was voluntary.
The state agency also has been working with primary care offices in suicide prevention.
“It’s about making sure anyone who is under care of a health care or behavior health care provider is being screened,” Hawkins said.
Need for more training
Meanwhile, since her son’s death, Teehee and others have successfully lobbied the Food and Drug Administration to add a black box warning label on the asthma medication he was taking when he died.
She also has worked to bring awareness to the need for more suicide prevention training among counselors.
“One of the things that I have come across is that there are not many counselors trained in suicide prevention,” Teehee said.
“That kind of threw me because we tell people if you are having problems to contact your mental health or behavioral health facility,” Teehee said. “But when they are not training themselves, it makes it harder for someone suicidal because they are not talking to the right people.”
She believes religious leaders who counsel others should take part in suicide prevention training.
“If you are a Sunday School teacher or a pastor, then I think you should be trained to recognize the signs for suicide,” Teehee said.
Teehee said she will continue to take part in fundraisers to raise awareness for suicide prevention programs.
“My son, he was the last person on this earth I thought would have left us that way,” Teehee said.