Farmer suicides spotlight lack of mental health care in rural America

Seven months ago, Jelle Hans Reitsma, a 37-year-old Dutch immigrant who owned and operated two large California dairies, succumbed to the financial strain of low milk prices. Under pressure from banks to repay millions of dollars in loans, and believing the only foreseeable way to raise money was to either sell his dairy herds or have them slaughtered, he took a handgun, drove to a nearby walnut orchard and committed suicide.

Reitsma wrote two notes before shooting himself. One was to his family. The other was a four-word note to the bank’s local branch manager: “Welcome to the kill.”

Stories like Reitsma’s are becoming more frequent in states like California, Maine and Colorado. Experts say Midwestern states like Iowa are better prepared to deal with rural mental health problems, but the risks are still high.

“To farmers there is a real kinship with the land and livestock,” explained Dr. Mike Rosmann, executive director of AgriWellness. “Ownership of a family farm — sometimes a farm that has been in the family for generations — is the triumphant result of a multitude of struggles. Losing the farm or the livestock is viewed as an ultimate loss, one that brings shame to the generation that has let down its forebearers and has dashed the hopes of successors.”

The psychological attachment farm families feel for their land and livestock is one of the lessons of the 1980s farm crisis — a time when farmer suicides and rural violence made front page news across the nation. Back then, Iowa and Nebraska, two states severely impacted by the farm crisis, developed crisis hotlines designed specifically to serve the needs of agricultural workers. Today, in the wake of natural disasters and in the midst of economic uncertainty, the hotlines are experiencing a spike in activity, likely helping to prevent more tragedies.

Sowing the Seeds of Hope provides behavioral health services to uninsured, underinsured and other at-risk farm families and ag workers in seven states. Despite droughts, floods and economic challenges to family-sized farm operations, the suicide rate has not increased in states that have these services.

AgriWellness and Iowa State University Extension jointly sponsor the Iowa-based Sowing the Seeds of Hope hotline, which serves rural people in seven Midwestern states, including Minnesota. It is the nation’s largest crisis help line for agricultural workers, and the calls are coming more often than they did even a year ago.

Though many of the calls the hotline has received from Iowa have been related to the impact of last year’s floods, Rosmann noted, “More recently, we have seen an uptick in calls that are related to market prices for swine and dairy.”

“In addition to the 20-percent increase in calls [when comparing the first four months of 2008 with the first four months of 2009], the content of the calls is changing,” Rosmann said. “The callers are reporting much more severe economic turmoil, more mental health symptoms and significant increases in mental stress.”

In times of inclement weather — for instance, severe storms, floods or droughts — the hotlines experience increased activity. The callers in these situations, according to Rosmann, are distraught but do not have the “intensity” of the callers during tough economic times.

“You probably aren’t seeing as many [suicides] in the states, like Iowa, where we have hotlines,” he said. “The hotlines have the effect of reducing the isolation and they create a vehicle people can use to contact someone. We don’t have quite as many suicides in any of the states where we have the hotlines and have other additional support services. [We have heard] that there were two suicides reported out of North Carolina, where there is no hotline. The same is true of California — there is no hotline there — or in Colorado.”

The statistical evidence of suicide reduction creates a good argument, he said, for why Congress should approve funding for the Farm and Ranch Stress Assistance Network that was authorized as part of the 2008 farm bill. The network creates a national crisis hotline for rural workers and also mandates additional behavioral health services in geographically rural regions.

There is insufficient data that examines suicide by occupational group, but several studies have demonostrated that suicide by farmers differs somewhat from suicide patterns by urban residents. The table above illustrates how farmers, if they decide to take their own lives, often align themselves with the cycles of farming. (Source: AgriWellness)

Federal officials, including U.S. Secretary of Agriculture Tom Vilsack, have signaled their awareness of the ongoing problem, but additional solutions may be hard to come by. “I’ve talked to farmers whose loved ones have committed suicide over this. I do understand,” Vilsack said during a rural community forum this week in Wisconsin.

Despite Vilsack’s recognition of what’s happening in rural communities, he said that he does not see many opportunities for additional federal intervention to turn things around. The U.S. Department of Agriculture, which recently approved $760 million in new farm loans, is considering restructuring loans and providing temporarily higher support payments, but ongoing discussions in the halls of Washington, D.C., will provide little comfort for agricultural families who field daily calls from creditors. Even if the idea is implemented, it is unlikely to be enough on its own.

Iowa has not yet seen the brunt of the burgeoning mental health crisis, largely because it remains ahead of the curve on rural mental health issues. The Hawkeye State not only provides an outlet for stress with its hotline, but it also offers follow-up care to agricultural workers who need it. The Iowa hotline has about 37 or 38 providers who have been contracted to give follow-up support to callers, Rosmann said. That means that Iowa residents need only travel 30 to 40 miles to access additional services.

“For many people that sort of distance is actually preferable because some don’t want to see a provider in their own town,” he said. “This usually has nothing to do with quality of care at local mental health centers, but has to do with the perceptions of what others might say if a family is seen going to the local facility or provider. So there is a perception of stigma attached to accessing behavioral health services, but that varies from person-to-person.”

In other states, rural residents tend to have more difficulty accessing mental health care.

“It’s a very complex picture,” Rosmann warned before beginning to explain the problems surrounding behavioral health services in rural America. “We have seen in Iowa the loss of psychiatrists and psychologists in rural areas. There just aren’t enough. But, we are better off than some other states. South Dakota is just terrible, and in Montana there just aren’t any psychologists and psychiatrists in rural areas. Residents there might have to travel 150 or more miles to get a court-ordered neuro-psychological evaluation because of lack of access.

“The numbers of appropriately-trained providers of psychology, psychiatry and substance abuse counseling in rural areas is half that of the same professionals in urban areas — and it is worsening.”

Further complicating the access issue for rural Americans is that there are very few medical educational tracks currently available that train health care professionals about the specific concerns that are often seen in more rural settings. And, outside of the rudimentary knowledge provided within those few agricultural medicine courses, there is no national curriculum in place for behavioral health professionals who intend to service rural areas.

“You simply can’t provide the information these professionals will need during a two-hour lecture,” Rosmann said. “We need a whole textbook and curriculum on agricultural behavioral health, and that is one of the things that we are now undertaking at AgriWellness.”

The organization plans to offer a six-hour course to professionals as a part of its upcoming biennial convention next month in South Dakota. Rosmann said that while recent discussions regarding mental health parity in conjunction with national discussions of health care reform are “a noble goal,” they don’t necessarily translate to actual access in rural areas.

“Having it on the books doesn’t mean that it is going to be adequately implemented,” he said. “I don’t know if it is a goal we are going to be able to achieve easily because parity requires the distribution of professional providers in ways that are quite different then where we are at currently. So, we are going to have to somehow get providers into the rural areas, and we’re going to have to change the reimbursement structure. Both of those are hard to change, but they are proper goals in my opinion.”

Lynda Waddington is a reporter for the Iowa Independent.