At a distance: Telehealth and rural suicide risk assessment

People in rural areas die by suicide at higher rates than those in metropolitan areas, and geographic disparity in suicide mortality has increased over the past decade. Innovative telemental health services can address rural suicide risk and overcome the shortage of mental health providers in rural communities by connecting rural residents with health care professionals remotely. However, risk assessment can be far more challenging over video than in person. It is therefore crucial to better understand risk factors for suicide ideation in rural populations.

To improve understanding of these risk factors, researchers from the Texas A&M School of Public Health studied suicide ideation (recurring thoughts of suicide) in a clinical sample of individuals living in a medically underserved region of Texas. The purpose of their study, which was published inThe Journal of Rural Health, was to learn how rural status and other clinical and demographic variables predicted suicide ideation in people using telehealth services for mental health care.

Carly McCord, PhD, an assistant professor at the School of Public Health and director of clinical services at the Texas A&M Telehealth Counseling Clinic, Kevin Tarlow, PhD, and Tina Johnson, MPH, studied data from more than 450 adults in five Texas counties who used telemental health services between 2010 and 2017. They recorded demographic information—such as gender, race and ethnicity, age and urban-rural classification—for each participant and used health questionnaires to measure depression symptoms and suicide ideation. The researchers then analyzed the data using three models: one that focused on suicide ideation and urban-rural classification alone, one that also included gender, race and age, and one that added on probable depression diagnosis.

The researchers found that suicide ideation was consistently prevalent across geographic and demographic groups, with an overall prevalence of 43 percent. The only statistically significant predictor of suicide ideation was a probable depression diagnosis (in other words, symptom severity), indicating that brief screening assessments might be more useful for mental health practitioners to detect suicide ideation than geographic or demographic factors. This may be especially true for people in medically underserved areas, many of whom face higher levels of psychological distress along with poverty and poor health care access.

These findings point to how clinical factors may outweigh demographics in clinical populations with a high need for mental health care. “What was most striking about our results was not that we failed to detect higher levels of suicide ideation in our rural clients,” Tarlow said. “The most surprising thing was realizing just how many of our clients—over forty percent—contemplated suicide in the weeks before seeking help. Thankfully these clients received the help they needed via telehealth, but we are left wondering about the individuals who are at risk and don’t have access to care due to geographic or other barriers.”

Telehealth technologies allow mental health clinicians to reach historically underserved rural populations; however, the complicated nature of detecting and managing suicide risk at a distance highlights the need for further research into clinical and diagnostic factors involved in suicide risk assessment. In addition, there is a need for further research into the rural-urban disparity in suicide mortality, in Texas and in other geographic regions.

“Undoubtedly, telehealth can be used to improve accessibility and successfully treat complex mental health presentations for individuals who have gone long periods without necessary care,” McCord said. “The more we know about these individuals, the better prepared we can be to offer quality care.”