LARAMIE, WYO. — After her family moved from suburban New Hampshire to the wind-whipped plains of southeastern Wyoming, Monica Morin embraced small-town life, forging lasting friendships and celebrating her own quirky style.  Dark-haired, with hipster glasses and a disarming sense of humor, Monica was a “why-not kind of kid,” her mother, Kim Morin, said. The kind who would wear a giraffe costume to the grocery store, just because.  Last year, during Monica’s sophomore year of high school, her mood began to darken. She turned to alcohol and marijuana, and some days withdrew from the close relationship she had always had with her parents, who, although long divorced, remained friends and partners in raising their only child. After her descent into drinking, she started cutting herself.  Ms. Morin was alarmed, aware that family history was not in her daughter’s favor. Her sister had developed bipolar disorder in her teens, eventually drinking herself to death. Her father had taken his own life when Ms. Morin was 19.  Monica’s parents sought help for their daughter’s despair, driving her two and a half hours to Casper for inpatient treatment. As the year drew to a close, Monica seemed to be improving, clinging to a fragile stability with twice-weekly counseling.  On the afternoon of Feb. 4, after Monica and her mother returned to their apartment from a doctor’s appointment, Monica said she needed to finish homework in her room. Some time later, she took a shower and asked her mother if they could snuggle on the sofa and watch a movie before going to bed.  “I love you, Mom,” she said, as Ms. Morin stroked her hair.  Not long into the film, Monica suffered a seizure. The paramedics who responded to Ms. Morin’s frantic call searched Monica’s room and discovered an empty bottle of over-the-counter allergy pills pilfered from her mother’s medicine cabinet. She died at Ivinson Memorial Hospital that night.  “You replay everything in your head,” Ms. Morin said in her living room recently, her voice shaking. “Wondering what else you could have done.”  Stories like Monica’s unfold with disturbing frequency across small-town America.  Rural adolescents commit suicide at roughly twice the rate of their urban peers, according to a study published in the May issue of the journal JAMA Pediatrics. Although imbalances between city and country have long persisted, “we weren’t expecting that the disparities would be increasing over time,” said the study’s lead author, Cynthia Fontanella, a psychologist at Ohio State University.  “The rates are higher, and the gap is getting wider.”  Suicide is a threat not just to the young. Rates over all rose 7 percent in metropolitan counties from 2004 to 2013, according to the Centers for Disease Control and Prevention. In rural counties, the increase was 20 percent.  The problem reaches across demographic boundaries, encompassing such groups as older men, Native Americans and veterans. The sons and daughters of small towns are more likely to serve in the military, and nearly half of Iraq and Afghanistan veterans live in rural communities.  The C.D.C. reported last year that Wyoming has the highest suicide rate in the nation, almost 30 deaths per 100,000 people in 2012, far above the national average of 12.6 per 100,000. Not far behind were Alaska, Montana, New Mexico and Utah, all states where isolation can be common. The village of Hooper Bay, Alaska, recently recorded four suicides in two weeks.  In one telephone survey of 1,000 Wyoming residents, half of those who responded said someone close to them had attempted or died by suicide.  In September, mental health experts, community volunteers and law enforcement officers gathered in Casper to discuss possible solutions. Among the participants was Bobbi Barrasso, the wife of Senator John Barrasso, who has made suicide prevention a personal and political mission.  “Wyoming is a beautiful state,” she told the crowd. “We have great open spaces. We are a state of small population. We care about one another. We’re resourceful, we’re resilient, we cowboy up. And of course, I’ve learned it’s those very things that have led to a high incidence of suicide in our state.”  Rural suicide arises from all the circumstances Ms. Barrasso noted and more. Despite a sleepy “Mayberry” sort of image, the realities of small-town life can take an outsize toll on the vulnerable. A combination of lower incomes, greater isolation, family issues and health problems can lead people to be consumed by day-to-day struggles, said Emily Selby-Nelson, a psychologist at Cabin Creek Health Systems, which provides health care in the rural hills of West Virginia.  “Rather than say, ‘I need help,’ they keep working and they get overwhelmed. They can start to think they are a burden on their family and lose hope.”  Country life can be lonely for people in the grip of mental illness or emotional upheaval, and the means to follow through on suicidal thoughts are close at hand. Firearms, the most common method, are a pervasive part of the culture; 51 percent of rural households own a gun, compared with 25 percent of urban homes, the Pew Research Center reported last year.  Experts also note a mind-set, born long ago of necessity, dictating that people solve their own problems.  Leonard Jacobs, who grew up in southeast Iowa, moved to Laramie when his wife, Sarah, enrolled in law school at the University of Wyoming. After 9/11, he enlisted in the Marine Corps, and he spent a year deployed in Iraq in 2005.  He came back a different man, Ms. Jacobs said — prone to anger and paranoia, troubled by nightmares and obsession over cleanliness and order. He refused to discuss the war and insisted on trying to fix himself, just as he had their car, their dishwasher and anything else in need of repair.  Eventually, fearing for the safety of their two children, Ms. Jacobs filed for divorce. The day she brought him the final papers, in February 2014, he retrieved a gun she had never seen from his truck and ended his life as she watched, horrified. It was their son’s birthday.  Mr. Jacobs never sought help. Ms. Jacobs says her husband’s sense of self-sufficiency combined with a fear of stigma to keep him from treatment. “For him, it was like admitting weakness,” she said.  Stigma is not unique to rural life, but it can become more acute in places where it’s hard to disappear into anonymity. Ms. Jacobs said she experienced this as she sought counseling for her own distress, walking past the awkward gazes of her clients in the waiting room.  A lack of privacy can deter people from seeking treatment. “If someone’s car is there at the known psychologist’s office or mental health provider’s office, then of course others in the community know,” said Bryant Smalley, the executive director of the Rural Health Research Institute at Georgia Southern University.  Even in cases like Monica Morin’s, where families desperately seek help, proper care can be hard to find.  Kim Morin learned that Laramie was not equipped to address her daughter’s complex needs. The Department of Health and Human Services reports that 55 percent of counties in the United States — all of them rural — do not have a single psychologist, psychiatrist or social worker.  Self-medication with alcohol and drugs can add to the challenges, and a study this year in The American Journal of Drug and Alcohol Abuse noted that rural treatment centers have “reduced access to highly educated counselors.”  Volunteers in Wyoming are trying to promote change from the bottom up, training citizens to talk to someone who may be in danger of hurting themselves. The program has been adopted by some of the state’s largest employers, community organizations and churches, said Terresa Humphries-Wadsworth, a psychologist in Cody who is the statewide director of suicide prevention for the nonprofit Prevention Management Organization of Wyoming.  Since the effort began two years ago, she said, referral rates to mental health services are rising. She cautioned that meaningful change took time, but said, “As we continue, we should see suicide rates coming down, because people are getting help earlier and earlier.”  In Wyoming and other rural settings, medical practices also are trying to integrate mental health treatment into a variety of settings. Patients reluctant to see a psychologist may nonetheless visit a doctor with vague complaints, such as headaches or trouble sleeping. A 2002 analysis published in The American Journal of Psychiatry found that 45 percent of people who committed suicide had visited their primary care provider within the previous month.  Identifying at-risk patients in private doctors’ offices or adding a mental health component to a public clinic can catch people who would otherwise avoid being seen at an office obviously associated with mental health.  “This is the same place they go for a cold and flu; nothing looks different,” said Dr. Selby-Nelson, whose office in West Virginia is in the same building and even has the same sign-in desk as other medical services, giving her patients a greater sense of privacy.  The Affordable Care Act has helped increase access by encouraging “whole patient” coverage that includes behavioral mental health, she said. An evaluation of the idea published in General Hospital Psychiatry in 2013 concluded that adding psychological services to a primary care office led to greater access and patient satisfaction.  Technology may also provide an answer, enabling doctors to reach patients in underserved areas via live video chats streamed to computers, television screens and iPads in clinics and schools.  “With psychiatry, the equivalent of a physical exam is a mental status examination, most of which can be done quite well with video conferencing,” said Dr. Kathleen Myers, the director of telemental health services at Seattle Children’s Hospital, which just completed a five-year evaluation of the concept.  “The ideal — what I think everybody wants — is that some primary care practice would have a conference room or a room next door where docs could just refer in their patients and a psychiatrist would see them,” Dr. Myers said.  Although such examinations are promising, logistical challenges remain. “Most practices, especially in rural areas, don’t have a lot of extra space,” she said, “and there’s not an easy mechanism for payment.”  In the meantime, many small communities racked by suicide are doing what small communities always have — pulling together to respond to crisis.  By the time school started this fall in Laramie, a friend of Monica Morin’s had formed a peer group at the high school, hoping to provide teenagers a safe place to talk about their struggles and to talk frankly with one another about thoughts of harming themselves. Monica isn’t the only classmate to have died.  “I have lost two friends in the past year to suicide, and that’s been pretty hard,” Madison Uehara, the Laramie High sophomore who started the peer group, told The Laramie Boomerang. “But another issue is, I nearly lost myself to it a few times.”  Dr. Humphries-Wadsworth says she hopes these efforts will begin to elevate the conversation around mental health, and to restore hope where it has been lost.  “We’re tied to one another,” she said. “On the one hand, that is really annoying, because everybody knows your business. On the other hand, it is how you really survive.”
People living in rural areas kill themselves far more often than those in urban settings. One reason: poor access to mental health care.