Office for Disparities Research and Workforce Diversity Webinar Series: Coming Face to Face With Suicide in American Farming

Transcript

CHRISTINA BORBA: Good afternoon, everyone, and welcome to the 2023 National Institute of Mental Health Rural Mental Health Research Webinar. My name is Christina Borba. I am the new director for the Office of Disparities Research and Workforce Diversity, which includes the Office of Rural Mental Health Research.

The purpose of our webinar series is to spotlight research on mental health disparities, women’s mental health, minority mental health, workforce diversity, and rural mental health. This afternoon we are spotlighting the work of Drs. Josie Rudolphi, Michael Rosmann, and Andrew McLean.

Let me tell you a little bit about this webinar today. The suicide rate among American farmers is serious and worsening and may not be well explained by either the lack of access to care or demographic characteristics. This webinar will focus on suicide in American farming and will emphasize the diversity in farming and ranching. Topics will include which hypotheses about agricultural suicide are more or less likely in the context of the current epidemiological research, where the likely points of leverage are, what is known and not known about the critical protective risk factors, what is needed to make telehealth successful within this community, the impact of farming, stress hotlines, and what the clinical opportunities and challenges are in addressing suicide in this community.

It gives me tremendous pleasure to introduce our expert speakers today. I will introduce all three of them and then we will pass it on to our first speaker. Dr. Josie Rudolphi is an assistant professor at the University of Illinois. She received her PhD in occupational and environmental health from the University of Iowa. Her research quantifies the burden of mental health conditions among agricultural populations, identifies risk and protective factors, and considers socioecological interventions to improve mental health. She is the director of the North Central Farm and Ranch Stress Assistance, a 12-state collaborative that increases and expands stress and mental health services to agricultural producers, workers, and their families.

Our next speaker today will be Dr. Michael Rosmann, who is a farmer and psychologist who lives in Pella, Iowa. He obtained his MS and PhD degrees in clinical psychology from the University of Utah. He has served on the faculties of the University of Virginia and the University of Iowa in addition to operating an organic farm and a consultation practice of psychology, mainly with farming people.

His professional work has contributed to the understanding of why people farm, their unique behavioral health issues, and why suicide is unusually common among farmers. He and his colleagues in seven midwestern states founded the non-profit organization AgriWellness, which conducted research for many years to identify the best practices in mental health that help farmers, ranchers, farm workers, and their families manage stress.

And then lastly today, we have the pleasure of hearing from Dr. Andrew McLean, who is a clinical professor and chair of the Department of Psychiatry and Behavioral Science, an associate dean for wellness at the University of North Dakota, School of Medicine and Health Sciences.

He previously was the medical director of the North Dakota Department of Human Services. Dr. McLean grew up in rural North Dakota and spent his summers working in sugar beet fields for the Agricultural Stabilization and Conservation Service. He obtained his medical degree from the University of North Dakota School of Medicine, completed a psychiatry residency at the University of Wisconsin, and obtained a Master of Public Health Degree from the University of Minnesota. He has received the American Psychiatric Association Bruno Lima Award for outstanding contributions to disaster psychiatry. Dr. McLean has lectured internationally on pertinent behavioral and public health issues and has an interest in collaborative models of care as well as individual and community resilience.

I am very excited for this webinar series today and it is my pleasure now to turn it over to Dr. Josie Rudolphi.

JOSIE RUDOLPHI: Hi. Thank you so much for having me. As Christina mentioned, I am Josie Rudolphi. I am an assistant professor and extension specialist at the University of Illinois Urbana-Champaign. Today, I am going to talk about what we know from a research perspective about suicide among farmers and ranchers and make some recommendations moving forward.

So, I think we all can acknowledge that suicide is a major public health concern. Suicide is a leading cause of death among most age groups. And more recently, we have started to – some of us have started to focus on suicides that occur among farmers and ranchers. We acknowledge that there are some unique occupational experiences and of course barriers to care that may complicate suicide in rural and agricultural communities.

When we think about research around suicide that occur among farmers and ranchers, we typically utilize two main sources of data. The first is from the Bureau of Labor Statistics. And this is a Census of Fatal Occupational Injuries or CFOI. CFOI is really one of the best fatal injury surveillance systems that we have in the US and that we can often get important information related to demographics, geographic information, and occupation. We will talk about how occupation is sometimes challenging in some of our large data sets.

Another data set that we have access to is the CDC’s National Violent Death Reporting System or NVDRS. NVDRS solicits information from all 50 states at this point, I do believe, at least 40, and collects really robust information over 600 different variables related to violent deaths that occur in the United States.

In addition to demographic information and occupation information, which is supplied by NIOSH, we also have information about mechanisms of death, health history, life stressors and even interpersonal situations. These two systems are really sophisticated. Like I said, they are quite robust. There are limitations as there are to almost every data set that exists. But we do feel fortunate as researchers to have access to these, either open access or through restricted access databases.

I am going to talk first about a study that was done at the University of Iowa. This is Ringgenberg et al. And this group analyzed almost 20 years of CFOI again so again the Census for Fatal Occupational Injury information.

And what the group compared was the rate of suicide per 100,000 full-time equivalent workers among farmers and ag workers and all other occupations. What you can see is that among all other occupations, the suicide rate remains pretty consistent over this 20-year time period, hovering near or at that .2 per 100,000.

And what we can see is that across this 20-year period, the rate of suicide among agricultural workers and farmers is not only higher but it is also far less consistent. I think what is interesting here and what some interesting conversation might lend itself to is asking what is inspiring these inconsistent rates. We know that when we consider rates, we are really standardizing the population so it is not necessarily a difference in population size. But it certainly could be social, political, environmental, or other sorts of occupational conditions that farmers and agricultural workers may be more vulnerable to, thus leading to a far less consistent suicide rate and opportunities to maybe predict or identify periods of extreme risk hopefully ahead of time.

What this analysis found is that suicides occur more commonly among farmers and agricultural workers than homicides but also that we really notice most suicides occurring among males, people who are middle age or older, and people who are white, and people who are self-employed. If you think about the farmers in the US, we acknowledge that 98 percent of our farms continue to be family-owned and operated. A lot of these farmers are likely operating small family-sized operations. They are likely working alone and they are likely males. It is very consistent with what we see across agricultural demographics in the US. It does not really highlight any maybe surprising finding. But it certainly would suggest that the suicides are occurring among a relatively generalizable sample of farmers in the U.S.

I sort of summarized some of the CFOI conclusions. And what I really appreciate about CFOI data is the ability to identify occupation and workplaces, which is not always easy to ascertain. But unfortunately, we really lack information around circumstances of suicide. We are really limited to information about demographics and information about workplace characteristics. But we do not really have an understanding of what that person is experiencing. We just do not have a lot of robust information around some of this suicide.

However, we do have that information from the CDC’s National Violent Death Reporting System. I had an opportunity to analyze some data with my colleague, Dr. Christina Miller. We published this paper in 2021. And we compared again suicides that occurred among farmers and ranchers to non-farmers and ranchers.

On this slide, I have some basic information. The number of suicides. We saw far less suicides among farmers than non-farmers. But this is probably indicative of differences in the size of employment. We have very few people who are engaged in farming and ranching in the US.

You will see that farmers were substantially older. The average age of suicide decedent was 60 and for non-farmers that was 47.

We also know that farm decedents were far more likely to have had a high school education or less, live in non-rural counties, they were not different from non-farmers and they were mostly male. Our sample was mostly white.

One thing we did find is that our farmer-rancher sample tended to be – were less likely to be veteran. We certainly acknowledge that there are characteristics that may increase risk for suicide and some analyses have suggested veteran is a risk factor for suicide but that did not necessarily come out in our sample.

When we considered incident characteristics of suicide in our sample, we found farmers were far more likely to die by firearm than other lethal means. This is probably not surprising for many people. What this does, I think, underscore is the importance of thinking about prevention efforts and we think about how we prevent suicide around firearms specifically when we talk about rural and agricultural populations.

I think what is important to note is that we did not necessarily observe farmers or ranchers at a higher odds of having a history of suicide, both thoughts and attempts. What this really does is challenges some of our perhaps pre-conceived notions about suicide trajectory in that somebody – suicide typically follows either suicidal thoughts or attempts, which maybe suggests at least on paper, I think this is a good point of conversation, that farmer suicides are perhaps somewhat more sporadic and we do not see some of those typical risk factors. But I do want to come back to that. We will talk about that in a second.

We think about life stressors and this something that is really interesting that we have through the National Violent Death Reporting System. Again, I mentioned we have over 600 different variables we can consider. When we look at life stressors, we often hear farmers talk about challenges and stressors related to financial situations. We hear farmers talk about chronic health conditions and chronic pain. And we hear farmers talk about sometimes stressors related to engaging in a multi-generational family farm.

What we found here is that farmers were not more likely to experience financial problems, not significantly more likely to experience financial problems. Farmers that die by suicide were not necessarily more likely to experience physical health problems. They were far less likely to experience job problems. A lot of again this – when we look at research around anxiety and depression, we find significant associations between things like financial problems and stress, environmental working conditions, and time pressures as well as interpersonal relationships.

But through this data set, again, when compared to the general population, we are not observing necessarily farmers that die by suicide more likely to report these types of problems.

I am going to move to the next slide and we are going to talk about mental health and substance use. Again, compared to the general population or the non-farmer-rancher population, farmers were not more likely to experience a mental health problem or have received mental health treatment. Similarly, they were far less likely to have reported an alcohol problem or a substance use problem.

Again, we think about where are the known risk factors. Where can we intervene? Where can we think about suicide prevention? We might say – like I said, suicide in farming communities may not follow that sort of assumed or presumed trajectory. But I think what is really important here is that we acknowledge where some of this information is coming from.

The NVDRS collects information about mental health, substance use, suicidality, financial problems, legal problems, family problems from the decedent’s next of kin. It might be a spouse. It might be a sibling. It might be a friend, who is offering this information to law enforcement, to medical examiners, et cetera. And what we do not know is how honest our decedents were with their friends, their colleagues, even their partners about what they were experiencing. We know that stigma is quite pervasive in agricultural communities, especially around mental health. We should not be so naïve as to think that some farmers were disclosing information about what they were going through, what they were experiencing, whether it be personal, or farm related. I think that is certainly something we need to talk about and acknowledge that as a potential limitation again to this data.

When we consider male versus female farmers, we notice that women were far less likely to die by firearm, which again speaks to – when we talk about prevention, thinking about access reduction for various types of populations. What we do see is that females were more likely to experience or at least have a history of suicidal thoughts. This is relatively consistent with data that is coming out of the general population.

Unfortunately, a lot of these analyses – we were precluded from doing advanced analyses and sometimes even basic analyses because of the small cell size. If there are less than five cases in a cell, we are not able to analyze that due to the potential for obviously identifying individuals, which is not something we would be interested in doing.

What that does though, however, is it creates challenges in looking at sub-population specific risk factors. We do not have a lot of good information or robust information around female farmers who die by suicide. Similarly, producers of color who die by suicide. We are not necessarily able to compare risk factors or think about how we might be able to intervene there based on the data, which I think is again – obviously, we want to be very protective of people’s information. We are not going to wish that these data sets were bigger so that we could do more analyses. What I think it does is it highlights information that we do not know, an opportunity for more research and certainly thinking about intervention.

We do see that women were more likely to have had a history of a mental health problem and have received mental health treatment. Now again, this information is also coming from the decedent’s next of kin, again, maybe a partner, a spouse, a sibling, a coworker, or a friend. And this might suggest that women truly were experiencing more mental health problems or having received mental health treatment prior to suicide. But it might also be indicative of again a woman’s or a female’s willingness to disclose information, seek help for a mental health condition where men perhaps were not as willing to disclose that sort of information. Again, challenges in collecting data and of course acknowledging that stigma is quite pervasive in the rural and agricultural communities.

We do have some limitations to the National Violent Death Reporting System as well as the CFOI systems and both is that they really rely – I should say the National Violent Death Reporting System really relies on information collected by medical examiners, law enforcement, et cetera, from the decedents, partners, friends, coworkers, et cetera. Again, the information – we cannot get information from the person we really want to ask at this point.

We also know that a lot of these systems are collecting decedent’s usual occupation, which is a little bit challenging especially when we consider agriculture. We know that upwards of 40 to 50 percent of farmers and ranchers are also working off the farm whether it be out of economic necessity or interest. But what that does is it complicates occupational codes in some of these databases.

In instances, where they are collecting one occupation and one occupation only, we are not entirely sure if we are collecting where they spend the most time, which might be in their off-farm job or they make the most money, which also might be on their off-farm job, and really which occupation is being listed.

From my most recent Google search, I do believe that all 50 states are now participating in the National Violent Death Reporting System but that is only recent. When we analyzed our data, we know that there were 40 states participating. And even within those states, some counties are not participating. I see that we are continuously growing that data set. And I think it is going to be, moving forward, much more robustly than it was in the past. But it certainly is the limitation to acknowledge.

That being said, these are some of the most rigorous and robust data sets that we have. We certainly appreciate and can acknowledge the time and effort that it takes to get this data. Unfortunately, like I said, there are some limitations, but I think it offers a lot of information when we think about resources and programming.

We really were perplexed. Dr. Miller and spent a long time talking about what our results mean and how this might be useful. And though we did not see that farmers and ranchers were necessarily at higher odds of having a history of suicidal thoughts or attempts. Even those life stressors that we typically think of that farmers experience did not really stand out. We do acknowledge that farmers and ranchers are experiencing these. And all our data suggests that they are not experiencing them beyond the general population.

What that means for programming is that we might be able to identify suicide prevention programs that have worked really well in the general population and think about applying those to agriculture. I think we often think that ag is so different. It is so different. It is so different. But maybe in some cases, there are really great programs out there that can be adapted and modified for our farmers and ranchers.

We did find primary risk factors that emerged as being age. People at 65 or older especially farmers and ranchers were at greater risk of suicide. Those that were less educated and geographic location. And what we found is that for females specifically, farmers and ranchers were more likely to die by suicide in micropolitan areas so not even the super remote or rural areas. And that we often think of more urban spaces of having better access to care. But what we find for female farmers is that might not necessarily be the case.

We are really excited about some of the research and results. We are really interested in talking to others, helping to think about what this means and where we go from here. But for now, I am going to turn things over to my colleague and friend, Dr. Michael Rosmann.

MICHAEL ROSMANN: Thank you, Josie, for that excellent review of the factors that describe suicide. I would like to mention that these are the best data that we have. But they are not perfect, as Josie indicated. There are still some drawbacks that we clearly do not have answers for. For example, some people can disguise the act of suicide sufficiently well that it is not reported as a suicide. And sometimes the coroner’s reports are not entirely accurate. But as Josie reported, these are the most useful data that we have at this time.

I am going to try to take off from here and you will see my contact information on the next slide and then we will go to the third slide, which indicates several studies. The common theme among these studies is that we are trying to understand why people farm and why they take their lives while farming. The first study was done in Southwest Iowa and it was printed in the Clinical Psychologist in 1990. The N for that study was 122 people who were followed over a period of 3 years as the funding made possible.

The next study comes from the work that was initiated at Wisconsin by the Office of Rural Health. In 1999, they received a considerable amount of funds from the Office of Rural Health Policy because there was an upswing in low farm prices during 1998. There were worries at the federal level among the elected officials and among appointed administrators that we could be seeing some kind of a crisis again.

Funds were given to the Office of Rural Health but Wisconsin eventually had to turn this project over to leaders from the seven states because they were limited by needing to work and serve Wisconsin only.

The funds were delivered to an organization, a nonprofit organization called AgriWellness. The board was made up of representatives from seven states. Besides Wisconsin, there were Minnesota, North and South Dakota, Nebraska, Kansas, and Iowa.

In 2005 and 2006, we examined over a 20 – it was a 26-month period. We analyzed data from 43,852 callers to farm crisis hotlines. Each of our seven states had a farm crisis hotline or helpline that served people 24 hours a day. These were operated by persons who had an understanding of agriculture and were familiar with the nature of difficulties that people in the farming communities have.

The members of the board for AgriWellness authorized several long-term studies to try to figure out what works to help people defray suicide. If we go to the next slide, you will see that there were reasons why people called the farm crisis hotlines. These data were taken from the 43,852 callers. Their primary purpose or the major reasons that they called the hotline were to complain about family problems, such issues as he is never home when I want to talk to him. I cannot talk to her anymore. She is always upset. These became a reason for 25 percent of people calling. Embedded with these family concerns often were financial issues and complaints so were these same issues embedded in problems with coping with daily activities, as you will see 28 percent of people cited that as a reason. Another 28 percent said that they felt depressed. Fourteen percent said they were stressed over finances. Five percent said that alcohol and drug abuse by a person in the family or by themselves was their main reason for calling the hotline and helpline. Gambling, less than 1 percent.

What we got out of this data are that people are feeling a great deal of financial difficulties as a major reason for contacting the hotline. But they also wanted the hotline to have workers who understood them. It became important for the hotline responders to be able to offer follow-up counseling and even immediate help if necessary, in a crisis situation. It was necessary that the callers knew that they were talking to somebody confidentially, that it was free, and that no personal records were being kept.

We found also that it was necessary to callers to have follow-up counseling when they needed it. And it was better if it was free than if they had to pay for it. Some people were unable to pay for it. In other instances, they did not wish to have a diagnosis registered on their medical history of depression because of the implications it might have for the future cost of health insurance and life insurance.

Here were the most common diagnosed behavioral health conditions of distressed farm people. These diagnoses were made in that same 26-month period in which 7,238 cases were diagnosed by trained professionals. It was important to the persons needing assistance that they see a professional who understood farming and the issues that they are going through. If they did not have any type of exposure to working with the farm population, we trained the remaining counselors and those who were already familiar in specific factors that we need to understand when working with the agricultural population.

For example, you cannot always have them come to the office. You have to see them at their homes often. You cannot necessarily see them when it is convenient for you as a therapist, but you had to be available when they needed you. Same with the telephone hotlines. They had to be available when people needed them and needed some assistance right now.

You can see that adjustment disorders, which are time limited and go away when stress remits, those were the second most common diagnosis. Then we had anxiety disorders including PTSD, excessive worry, panic, anxiety phenomena.

Go to the next slide. The additional diagnoses that were common were some forms of depression with major depression much more common than bipolar disorder. We saw depression often after the person became anxious or the family became apprehensive and anxious. We saw depression occur as a result of fatigue in trying to resolve the financial issues or whatever the problems were.

We do see or we did see that the majority of the callers during our study were female, about 57 percent. Now that has changed. More recently, we are seeing a higher number of male callers than female callers to those states that still have hotlines and helplines. Of the seven states that were original participants in the AgriWellness organization, those that maintained hotlines still are Wisconsin, North Dakota, South Dakota, Minnesota, Nebraska, and Iowa.

We did not see substance abuse as the primary diagnosis except in about seven percent of the cases and that was pretty similar to what we found from the farm crisis era in the 1980s when about five percent had reported alcohol or some type of substance as a primary or the primary problem. Here, it was seven percent but it was a co-occurring diagnosis about 40 percent of the time.

What we did not see are personality disorders in the agricultural population nor very many people with psychotic disorders. These typically are so debilitating behavioral health illnesses that they render the patient unable to carry out the activities that are necessary for farming. Over many many generations, it is possible that people with a psychotic tendency may have been sorted out.

What we did see and importantly see is that 1.9 percent of that 43,852 callers reported suicidal ideation. I wish we had asked them if they had made a prior attempt but we did not. That was a mistake that I think we made.

We found that 77 of the 685 callers who were concerned about suicide in some fashion, 77 reported a suicide plan to the responder on the hotline. Fifty-six percent of persons who called the hotline had already made an attempt.

I can remember one case in particular. The hotline for Iowa contacted me because the caller said that she knew me and so they transferred the call over to me. When I spoke with her on the phone, she had already ingested, she said all the remaining pills in her bottle. She could not tell me what kind of substance or medication they were. I could tell as her voice was becoming more strained and her speech was becoming hesitant that the effects of the medication were having – you could observe them. I kept her on one line while I told her I was going to have to call someone. Who would you like me to call? How about your husband? She said he does not have his phone with him. I said alright. I will be calling the sheriff for your county. I knew where she lived. I knew the county. I contacted the sheriff who answered – a person answered and eventually I spoke with a law enforcement officer who said I am going out there right away. I know where the family lives. I am aware of who they are. I kept the caller on the phone the entire time. She eventually dropped the phone and fell to the floor. I could hear the thud. Within just a couple of minutes, the law enforcement officer showed up, picked up the phone and said who is this. I said it is the person who called you. He said I will take it from here. But that is a type of caller that we sometimes had to deal with. Let’s go to the next.

I want to point out that there are some really important things that are happening in the agricultural population that sometimes we do not think about. These are only the results of polls. You have to take them with a grain of salt. But they do tell us something important. They tell us that these were polls conducted by Morning Consult but they were commissioned by the American Farm Bureau Federation. The first one was undertaken in April of 2019 before COVID really struck in full force. And it was repeated in December 2021 with the same subject pool. The results were similar except that they were a little bit more positive. That is, if 91 percent in 2004 said that mental health is important to them, it went up a little bit in – if they said that in 2019, it went up a little bit in December 2021.

What is important about this is that the responders in rural areas and among the 81 farmers who were part of that sample is that these people are able to talk about mental health in ways that they formerly would not have. They are aware of stigma though and 75 percent said it is important to reduce stigma about mental health. It is one of the reasons why I prefer the term behavioral over mental.

If we go to the next slide and you will see these. You have these slides so you can keep them with you and study them. We found that both rural residents and farmers, 72 percent of the responders said they would be comfortable talking with a therapist in February of 2019 and that went up a little bit in December 2021.

The major event that they cited as their reason for feeling distress is the fear of losing the farm. I find that personally when I talk to clients who are going through apprehension and fears that they will not be able to make payments on a loan and that the resources needed to hang on to the land are being threatened. That was the major reason that perhaps the suicide rate went up so much during the farm crisis era of the 1980s. At that time, for about a two-year period, the rate of suicide among farmers was double what it was prior to the farm crisis, so we know that economic concerns are an issue.

It is important to see in these poll results that many of the rural residents and farmers said that caregivers should have specialized training about mental health issues. That says a lot. That means that we need to do a better job of preparing the caregivers in rural areas and specifically those who work with the agricultural population. We can go to the next slide. Ah, that’s because that’s the last slide.

I am going to summarize a couple of things though. I want to point out that our work helped to define what are best practices that can modify the rate of suicide among farmers. These best practices that we found over our many years of research were having the option of a farm crisis telephone or hotline or electronic email place to contact for assistance. It was important that the people that answered the telephone understood farming, and it was even more important that the counselors who worked with the farm population understand agriculture. When they did not understand agriculture, we found that they often terminated counseling early. But when they found the right counselor, 91 percent said that they would recommend this person to another farmer or they would go back to see this person.

We also found that another best practice is what we are doing here today, training and educational consultations and seminars. The more people understand about farming and about mental health or behavioral health the better because the more they understand, the less fears they have, the less stigma develops. We do not have all the answers, but we know that these characteristics are important to work with.

We also found that it was important to place literature about signs of stress for suicide in places where farmers will notice them. It is now in all of our farm service agencies around the country because farmers have to go to the farm service agencies operated by the USDA.

In summary, these best practices, hotlines and helplines, culturally understanding therapists, free counseling when necessary, community education, and making information available when people need it. These are best practices. We have much to thank the media for because hardly a week goes by or a month goes by when a farm magazine does not have something in it about signs and signals of stress or other things that have to do with behavioral health.

We are very grateful for the improvement that the agricultural population has of behavioral health. But we are not done yet. There is far too much that we have not grasped and proven. We do not even know for sure if having these services available necessarily always results in a lower suicide rate. We have pretty good reason to believe it.

Our work became the basis for the Farm and Ranch Stress Assistance Network that Josie had mentioned. This is a USDA-funded program. It is up for renewal in the upcoming farm bill that is being debated now. It is not certain whether it will be passed this fall. Probably not. It may be continued on. But eventually, it will come up again and I hope that we renew and even expand the funding of the Farm and Ranch Stress Assistance Network.

With that, I thank you so much for your participation in this. I would like to turn this over now to Dr. Andrew, I call him Andy, McLean.

ANDREW MCLEAN: Thanks much, Mike. One of the things that Dr. Rosmann talked about and Josie also, is the importance of data. I was just at a meeting on maternal mortality, and they were discussing the issue of coroner reports. As we know, many coroners are actually appointed or elected lay people. When Mike pointed out that there are ways to either hide the actual incident or at least not necessarily go over it with a fine-tooth comb, that certainly impacts the data as well.

My dad was a country doc and he said half of what he did was mental health, and he did not know what he was doing. I have a real soft spot in my heart for primary care providers trying to assist individuals in heath care. This is something that you may have seen before, the Wellness Wheel. There are lots of different aspects to it. For some people, they are weighted fairly similarly. For others, these individual parts are weighted quite differently. But certainly, farmers, ranchers, individuals who we are discussing today have aspects all throughout the Wellness Wheel. As both Josie and Mike were saying, finding a way to engage with those individuals, helping them to be able to articulate what they are going through, their concerns, is going to be 90 percent of the battle.

We certainly know farming is a wonderful occupation, a calling, as many of us have callings. But it is also extremely stressful. I was particularly struck by the CFOI slide that Josie had pointed out and Mike had talked about too. The significant fluctuations in suicide rate compared to the general population. That will certainly inform us in terms of how we might identify those risks and intervene.

The most recent survey, which was done through Rural Healthy People 2030 just this spring, indicated that actually mental health and mental disorders and addiction, have moved up to the top spots of concerns of rural individuals whereas before it was primarily health care access and quality. I do not think that surprises us. Certainly, for the last half a dozen years, we have been hearing more and more concerns about mental health and certainly COVID added to that concern. As you can see, across the various regions, the top six are very consistent across the entire US.

Many of you have seen this slide before. There are disparities in terms of mental health providers. Certainly, the advent of telepsychiatry, tele-behavioral health has had an impact. I know that both Josie and Mike have data on that. Just having increased access does not necessarily equate with individuals using it. But these sorts of maps and diagrams also point out to us the significant need and discrepancy that there is in rural areas in terms of mental health.

We know that individuals in rural areas are more likely to die from heart disease, cancer, unintentional injury, chronic respiratory disease and stroke. And Josie had pointed out that there are not necessarily significant increases in chronic disease states among the individuals who died by suicide who were farmers. But we know that access to health care particularly more specialized care is a significant issue.

And then also, as we have been talking about the suicide rate being significantly higher and as pointed out earlier with farmers, ranchers, significant fluctuation compared to the national cohorts.

Interestingly, there has been a lot more work being done on added risks, which includes climate change. Lots of weather variability. In our own state, we had significant late blizzards, which impacted calving, the increase in invasive plants, issues regarding irrigation, increased pests. There are also adaptations though that they are working on in terms of grazing management, water efficient varieties, really protecting soil health and pest tolerance and drought-resistant species. As these stresses are added with changes in climate, there are certainly things that can be looked at to reduce the significant financial risks but also farmers need supports with that. And then that entails also changes in legislation, et cetera.

One of the reasons for this talk is to also help NIH and NIMH look at what other areas and opportunities for research are there. Interestingly, with climate change, most of the major studies have been out of Australia.

Mike, I was laughing when you talked about mental health versus behavioral health. I was presenting at a rural mental health symposium in Australia and I really like using behavioral health and they did not like that at all. I think those were just cultural differences in terms of terminology.

But we know that there are significantly more increases in irritability, in violence, with heat, episodes of heat, in particular, high heat. I think there are opportunities there for the impact of climate change on farm and ag families. Also, rural populations suffer heat-related illnesses at a significantly higher rate as well.

Another area that I have been interested in primarily from a medical background in working with providers is the impact of what we call second victim impact. That is when an individual dies by suicide. It is a ripple effect. Obviously, the impact and the burden of the family is profound.

But also, we are talking about individuals in smaller communities. Someone who may die by a violent cause, or a significant negative impact may have a larger impact actually on a community in a rural area, including micropolitan areas than they would in a major urban setting. I think that that is really important. Whether we are talking about an individual clergy member, a person at the town café, the banker, the primary care provider, others who – the implement dealer, others who would be working with and know those individuals very well and the families very well.

As Josie was talking about the farmers being less willing to open up and talk about their concerns although Mike’s data said that that is getting better, it made me think about in comparison to another population. I used to be on the Impaired Physicians Board. We would see and continue to see significant stigma and difficulty in incentivizing providers, health care providers to admit to having a problem. There are significant external risks to them doing that and had been before whether it is medical licensing, having to indicate on your applications why you are being treated, et cetera.

We have been changing the system to reduce those negative impacts of admitting to having concerns or even making safe harbor for people to not have to actually admit to that if they are actually receiving help.

I was just curious. Externally for physicians or providers, there are outside barriers. What is it about the farmers themselves that makes it less likely for them to be able to articulate this to their families, et cetera?

I was also curious when Josie had put up that data that showed less mental health diagnoses for farmers but clearly depressed mood and other observable sorts of symptoms that one could see, which indicates to me that yes indeed we are not being able to diagnose or assist people in identifying their illness, but people can see it.

And that’s why I think I will talk a bit about collaborative care, how that is very important. Mike talked a lot also about access to care, that there are many individuals who have the opportunity but do not necessarily utilize it. We are seeing a lot of new data on post-COVID and the use of telemedicine, tele-behavioral health, who is using it, who does not, why don’t they use it. Are there certain subpopulations, clusters that are more likely to want to come in and visit. They may be coming into town for other shopping or other tasks that they have versus necessarily depending on telemedicine. I think there are other opportunities there in really diving down deeper in seeing who it is and why are they using certain types of care.

There are lots of opportunities for training models. Mike talked about all of the work that he has been doing in training individuals on crisis hotlines. Certainly, utilizing peer supports and we know, as has been outlined today, how important it is for farmers and agricultural families to know what the culture is like, what the experience is like and that helps them to certainly have a good relationship with those that are caring for them.

Collaborative care. I am going to talk about it in a second. But this is really a model. We are never going to grow enough therapists, addiction counselors, psychiatrists, psychiatric providers to meet the need. We have to be smarter. We have to do things like utilize peer support, call-in hotlines. But we also, as Mike had mentioned, utilize the most trusted source, which is the primary care provider in helping them to work with individuals with mental health concerns. I will show that on my next slide.

Lots of training to be done whether it is mental health training among providers, paraprofessionals, lay people.

There is something called Project ECHO, which is a format which really democratizes medical knowledge. It has been used out of the University of New Mexico. It was started actually by a gastroenterologist who had an eight-month waiting list to treat hepatitis C patients. He said I can teach my colleagues out in the rural areas how to do this. He came up with a format of a 15 to 20-minute presentation over the noon hour. They would present a case in the field. They would get education credits. His waiting list went down to two weeks because everybody else felt more and more comfortable. We have done that medication-assisted treatment in rural areas. And about any topic you can think of outside of medicine whether it is having to do with education, law enforcement uses that format. That is something I think that people might be interested in as well. You can get information from University of New Mexico.

Lots of work is being done in telemedicine. I do not need to belabor that. There is actually a lot of work being done on training rural EMTs and paramedics. I also recognize though that many of these individuals are volunteers. I was a volunteer EMT when I was 17 years old. But it is again utilizing trusted people in the community or at least in the county or the region to do some other work that may not be accessible otherwise.

Collaborative care is – it initially came out of the University of Washington, and it was a psychotherapy model actually. There are different ways in which mental health providers can help have access. One of the models is a patient comes to see me directly. Enough of that happens though then there is a bottleneck for people who really need to get in to see me.

Another is just curbside consults. Somebody calls me up. I am available. I say this is what you do. Another is what I do with the federally qualified health center is I meet with them every week and we go over cases. I have access to the electronic health record. I do not treat the patient individually. I help the providers actually manage their care. That is the kind of a model is if there is the ability to have a behavioral health therapist or a manager. It can be a nurse. It can be a therapist. It can be an addiction counselor, social worker, someone with mental health experience help the primary care clinic to work with a consulting provider. It does not have to be a psychiatrist but someone with mental health expertise to assist them in their what we call the patient panels to be able to look who is doing well and who is not. Then if you can do that, most of the time that is where patients want to be treated. They want to be in their primary care office. They do not want to have to go out and see a specialist. If we can actually reduce the burden early on so that the symptoms do not become so severe, then that frees up the specialists to be able to see the people that really are in dire need who need to go to that specialty provider or clinic.

Things are turning around so that third-party payers are willing to at least pay some for the clinic at least to be able to bill for that. They do not necessarily allow for the consultant to bill. But it is a reasonable team approach in certain areas.

I just wanted to throw this out there. Part of what my job is as the chair of the Department of Psychiatry where we teach not only medical students, but we have psychiatric residents who are trained to become psychiatrists. My colleague, Dr. Olson, who grew up in rural North Dakota and I grew up in rural North Dakota, we said we need to do more outreach. What we developed was -- as part of our psychiatric resident rotations, we have our third and fourth-year residents do telepsychiatry one-half day per week and then one day per month we have them go out to the more rural areas. Even though these are not – there may be some of the larger cities and one of the reservations – it is getting people out, getting them to know the community, getting them to know the individuals and to know the culture. It has been very successful. We have been able to actually have them recruit some of those individuals as well.

Also, part of the incentives is we have been able to utilize grants and loans to those providers to some of our residents who are going on to rural areas. There are also state loan forgiveness programs for behavioral health professionals whether they are social workers, therapists, addiction counselors, et cetera.

There are federal programs. I was a member of the National Health Service Corps early in my career. And then there are other higher education programs, which incentivize people to get training and perhaps go into a career in behavioral health.

I will not turn it over to Christina.

CHRISTINA BORBA: Thank you, everyone. This was such an engaging presentation. We have some questions that are coming in through the chat, which is great. I am going to ask all three of you to turn on your cameras and unmute your microphones. Just a real quick announcement for the participants on the webinar that the slides, the recordings, the transcripts will all be posted on our NIMH website in the coming weeks. That question has come up a few times already. And then also, CEUs are not available for this webinar.

There are two comments that I just wanted to start with. One comment from one of the participants said in Iowa, we are moving towards using brain health to replace mental health. Behavioral health is also being used to encompass co-occurring brain health and substance use disorders. We have had some discussion about language and talking about cultural differences and going to Australia and them saying no, behavioral health is not something that we use. That was an interesting comment from this participant in Iowa.

And another comment is that there was news that just came about farmers now starting to work at night to avoid heat-related illnesses as we are talking about climate change.

Some questions for you three. I have been keeping track in the Q&A. The first question says does the increased rate of suicide in rural communities have a relation to higher access to lethal methods. I will let the three of you decide who wants to tackle this question. 

MICHAEL ROSMANN: I will start. This is Mike. Andy, I have been in Australia also. The method that was primary in Australia prior to 1993 was the use of guns. But there was a mass murder that was carried out with a gun after which the Australian parliament made it a requirement that the only people who could have guns are law enforcement persons who registered as hunters and hobby users of guns. Each township had to have at least one person who had a gun to dispatch injured animals such as kangaroos that jumped in front of moving vehicles. The reduction in guns in Australia did not impact the rate of suicide. Different methods were found.

JOSIE RUDOLPHI: I think it is an important conversation to be having. It speaks to (inaudible) have a lot of information around. But I think what is concerning about guns is just it is an incredibly successful means of a suicide and it is very – there is a finality to that. I know conversations around access to guns are challenging. But I think conversations around safe storage and those are the conversations we should be having among all communities, not just rural and agricultural but definitely in rural and agricultural communities.

ANDREW MCLEAN: Absolutely. One of the places where I oftentimes struggled was in the fall when individuals wanted to be hunting with their families and that was such an important bonding time for family members and we had numerous conversations with individuals and entire families on that.

I do not want to cheat and ask my own question but I was curious about the data as to whether or not there is a particular time of year that farmers are more likely to die by suicide.

MICHAEL ROSMANN: This is Mike again. That data has been changing. Originally, Paul Gunderson did a study in the early ‘90s that looked at the times of the year and found that – and times of the week – found that suicide was much more likely to occur on Saturday night and Sunday night in general among farmers too. It was more likely to occur during planting and harvest season.

There is some more recent data that has come out to show that it is changing or maybe we just cannot predict it very well. We do see a higher rate during such times as when taxes are due and rental agreements must be honored. Any time that there is something that is perceived as a severe threat to the livelihood of the occupation then there is a higher chance for suicide to occur.

CHRISTINA BORBA: We have had some questions come through, which were actually some of my own questions as well as really thinking about the impact of COVID-19 and has that had any effect on suicide rates in the farming communities. That was also one of my questions as well and really thinking about how has the past three and a half years really affected our farming communities?

JOSIE RUDOLPHI: That is a really good question. The data that I presented today – most of it was from the early ‘90s to about 2018-19. We have (inaudible) to get more recent NVDRS data so that we might be able to say something about COVID-19. Now, we know that COVID-19 was challenging for everybody, not just agricultural producers. It will be really interesting to see what those statistics show. We do know that COVID was really challenging for agricultural producers. We did a survey of farmers in Illinois. What came through was obviously people’s concern for their health and their safety. There were tremendous challenges related to securing inputs, costs of inputs. Oftentimes we saw new variants emerge. We also – and this is not to say that correlation is causation but it was during very busy agricultural times so spring and fall where people were trying to get situated and ready either put a crop in or take a crop out and at the same time, they were ill. Their farm workers were ill. Their family was ill. There were a lot of challenges there.

It is a really great question of how COVID-19 impacted suicide rates. That is something I think we will only be able to begin talking about because there is usually a delay of a year or so in getting that data.

MICHAEL ROSMANN: The data showed – it was national data reported by the CDC that the overall rate of suicide in the United States went down in 2019 and again in 2020 and then went back up. Those were the years when COVID was occurring, which we think that same phenomena occurred in agriculture. The suicide rate went down during COVID. We would not have expected that. I do not know what all that means.

CHRISTINA BORBA: There are some questions too in the chat, Mike, I think as you were talking about the crisis hotlines. Some of the questions that have come up are about the conversation about whether farmer hotlines or helplines are still necessary now that 988 exists and is being promoted so robustly. And this participant was really looking at your comments on that and from the others as well about 988.

MICHAEL ROSMANN: Thank you. That is also a good question. I think the use of technology has greatly impacted agricultural safety and health. The invention of the cell phone has certainly improved the response time to events, crashes, and has reduced the death rate, I think, among farmers.

But there is also a downside and that is that farmers now hear information on a regular basis and sometimes begin to stew on it while they are out there alone on the tractor or sometimes they hear the bad news and make some choices that are not wise. I do not think we have all the data in yet. But I think there is more benefit from technology than we have fully grasped yet.

JOSIE RUDOLPHI: I can speak a little bit to a Concern Hotline. I direct the North Central Farm and Ranch Stress Assistance Center and we support and partner with the Iowa Concern Hotline to provide hotline resources to the 12 states in our region. Annually, that phone line responds to almost 10,000 calls. Most from our North Central Region but also around the country.

And what we really appreciate about that (inaudible) is that you can call and ask – you can get some financial counsel, legal counsel, stress counsel – staffed by people who know and understand agriculture. While I think 988 is a tremendous resource, I am thankful that we have it, what we might want to do is make sure that farmers are using it. We do not want to take out any hotlines until we know who is using 988.

And then we also need to think about staffing or having options for people who are in rural and agricultural communities. If you are a farmer, press 2. If you are a veteran, press 3. Just because we know farmers want to talk to somebody who understands agriculture and at least talk the talk.

CHRISTINA BORBA: Which is interesting because actually, Josie, you knew this. It blends right nicely to the next question, which is really thinking about specialized training for mental health workers at these call centers has not been explored to maybe have retired farmers trained as peer counselors to either staff the call centers or visiting the farmers that are in crisis.

JOSIE RUDOLPHI: I read that question. I think it is a fantastic opportunity. I know there are a project similar to this in either Ireland or England where they are working – they are using a peer support model in this way and they are taking somebody who really understands agriculture and leveling them up in terms of having confidence and skills around conversations about mental health and suicide prevention.

We are also doing that. We are training health care providers to be more savvy when they talk to farmers. We are training them in – we are calling it agricultural literacy. We talk a lot about training everyone else in mental health literacy. We sort of flipped the coin and said let us make sure that health care providers are trained in agriculture. We are offering programs for health care providers so that they might better connect with and retain famers’ alliance because we know we have some data to suggest farmers are interested in utilizing free or low-cost professional behavioral health services. But that door could be closed pretty quickly if they are not connecting, like anybody, if we are not connecting with the provider.

CHRISTINA BORBA: Anyone else before I move on to the next question?

MICHAEL ROSMANN: I certainly agree with everything that Josie has said. It is interesting that we found that the educational degree was less important for counselors than that they understood agriculture. I think that it is more important to have a person who is providing assistance and that has credibility with the recipient of the care. If there is no credibility, there is less likely to be learning and profit benefit that occur.

CHRISTINA BORBA: Questions keep coming. Next question I have is the demographic data shown by our speakers today did not comment on environmental factors such as the season or the altitude, which has been established as moderating risk for suicide. Is there any research on these factors with regards to modifying risk for farmer suicide? We are thinking about environmental factors. Although we did talk a little bit about climate change.

JOSIE RUDOLPHI: I think we certainly acknowledge seasonality as a challenge in agricultural mental health in terms of activity and sometimes a lull in activity and with that, there is a lot of financial stress and time pressures.

I was looking through some of the papers about (inaudible) specifically and I do not see any report on season where a lot of farmer suicides occur. I do not know if that is something we have access to. We, of course, would not be able to (inaudible). I do not know if the CDC offers information by season but something worth exploring.

Thinking about how we beef up prevention efforts during certain seasons and making sure people have access to what they need. We cannot take the seasons away (inaudible) think about removing risk factors --

ANDREW MCLEAN: On the northern tier, it is estimated that probably up to 15 percent of the population might have seasonal affective disorder as well. That may or may not play a role.

JOSIE RUDOLPHI: It is a good point.

CHRISTINA BORBA: Okay. We still have time so I am going to keep going. Do you think that life insurance payout has anything to do with how many deaths are reported as suicide in the farming community?

MICHAEL ROSMANN: I do not know of any hard data about that. I think the life insurers could answer that the best. I think in many cases, the insurers do the best job of identifying the cause of death because that is important to them. But I just really cannot speak to the issue any more than that.

JOSIE RUDOLPHI: I have certainly heard anecdotally that that might result in underreporting of suicides. Dr. Rosmann, I do not have any – it would be hard data to collect. Right? Quite challenging. But I think it is certainly potentially a limitation to look in to and a challenge in accurate data collection and reporting.

CHRISTINA BORBA: One actually just came in and it says do you have recommendations on where an agency could get agricultural or rural-specific cultural training.

MICHAEL ROSMANN: I can start with that and Josie also knows that. A program started at the University of Iowa to develop a course called agricultural medicine. That course was initiated by Dr. Kelley Donham. It included specialists in many of the areas of health and medicine such as dermatology, oncology, audiology, and behavioral health was even a part of that. That course is now being offered in about at least 15 places that I know of in North America plus a couple of places in Australia, Europe, Turkey, and there may be more than I am not aware of.

I wish that we had a course in what I would either call agricultural behavioral health or maybe we are going to have to call it agricultural brain science or something that focuses on the unique problems that farmers experience and what can we do to lessen the impact of these factors.

JOSIE RUDOLPHI: And we have a couple of partners in our region who are developing – I mentioned those agricultural literacy courses. If somebody is interested – it is very much tailored towards health care providers. But it really describes this as a commodity. A lot of people are selling their products, look at the seasonality of agriculture when we interviewed farmers. And their stories, their voices literally weaved throughout the course. And so it’s interesting. If someone is interested (inaudible) Midwest. But reach out to me and I can either connect with somebody in your region who might have created a similar course (inaudible) useful.

CHRISTINA BORBA: Thank you for that because definitely there are some comments going about can you post some of the link to these courses and stuff in the chat. I really appreciate you offering that. People could reach out to you and ask for some specific information. As well, people can reach out to us at NIMH and we can also connect you to our speakers and stuff.

I am being very cognizant of time. I want to make sure that we end right at four. I am going to ask each one of you that if you have a magic wand, which none of us do, but if you did, what are the top one or two things you would do to improve the mental health of our farmers. Josie, I will start with you.

JOSIE RUDOLPHI: Off the top of my head, I would increase access to professional behavioral health care. I would argue that if we all spent 45 minutes a week in therapy, the world would be a much better place. We know that farmers are hungry for these types of programs. They are being utilized in the states we have them offered so increase access there.

The other thing I would do is just increase everybody’s mental health literacy so that we feel comfortable asking your friends and neighbors, how are you doing. I am worried about you. I have noticed X, Y, and Z. We spend a lot of time not being in people’s business right now (inaudible) I would say get back in people’s business and I would really try to bring the community back to our rural and agricultural spaces.

MICHAEL ROSMANN: I would say ditto to everything that Josie said. I would add that I think we can begin to include training in agriculture in colleges, in vocational agriculture in high school, in FFA, and 4-H and in graduate training in agriculture but in a whole range of fields that equip people proactively with knowledge to prevent the development of dangerous disorders and problems.

CHRISTINA BORBA: Thank you. And Andy?

ANDREW MCLEAN: Ditto to everything else. I think just utilizing the relationship within the community. I mentioned primary care. There are lots of opportunities to do easy screening and many clinics do that. If they have a good relationship with their primary care providers and they are honest about it, that is a wonderful opportunity right there to identify concerns. Then like I said, if there is a way to embed behavioral health assistance there, that would be very useful.

CHRISTINA BORBA: Great. There are a lot more questions in the chat that we did not have time to get to but like our speakers said, feel free to reach out to them or feel free to reach out to us and we are happy to continue this conversation offline.

I want to really thank our three speakers today. This is an area that NIMH is very much committed to. We had a huge showing in people who registered for this webinar so it is absolutely a really important topic. I am just so pleased to have the three of you join us today. So, really thank you for this.

We are going to put up the slide for our next webinar series for everybody. It is going to be next week, which is – is it next week? It is next week. Thursday, September 21. I cannot believe this. Starting at 12:30. It is engaging community stakeholders to reduce mental health inequalities in the Hispanic community. Hispanic Heritage Month starts in just a few days. We are really excited to highlight this webinar as well. Again, if anyone has questions about registering, feel free to email our office.

Again, thank you very much to our three speakers today. This was really an incredible webinar. Here is our email address. Please feel free to reach out to us. We did not get to all the questions, but we will respond if you send us an email and we will connect you to the speakers as well. Thank you, everyone. Have a great rest of the week and a lovely upcoming weekend. Take care.