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For millions of Americans, living with the isolation and anxiety that Covid-19 has brought can be a traumatic experience. For others, it can be too much to bear. 

Sean Tylor Sloan, 18, of Mitchell, South Dakota, was one of them.

Tonya Tiede-Webb, Sean’s mother, lived 20 minutes away from Sean in Parkston, a town of 1,400 in southeast South Dakota. She said Sean was a brilliant child, but he struggled with the emotional toll of unemployment and stress, exacerbated by his isolation during the Covid-19 pandemic.

“We knew he was having a hard time with all this, but none of us knew it was this bad,” Tiede-Webb said.

Sean had recently lost his two jobs, broken up with his girlfriend, and lost the child his girlfriend was carrying when it died in utero. The pressures of mounting bills, the stress of limited money and the uncertainty of what was coming next are thought to be what caused Sean to take his life on May 8.

Sean’s story is part of a bigger trend. According to the Journal of American Medicine, the country faces a “perfect storm” of causes to increase the number of suicides rates.

Suicide rates in America have been rising for the past two years, the journal said, and with the pandemic, it is expected to continue its upward trend. From rising unemployment and economic insecurity to mental health challenges in our health care providers to social isolation and a decrease in access to religious and community gatherings, article authors Mark Reger, Ian Stanley and Thomas Joiner said they anticipate the U.S. to have its highest rate of suicide since 1941.

In Tennessee, former Representative Patrick Kennedy, a mental health advocate, said in a press conference that calls to suicide hotlines have increased by 800 percent in that state.

“The tragedy of Covid is it exacerbates this already prevalent mental health and addiction crisis. No one doubts that mental health and addiction is real,” he said. “Every single American has been faced with a mental health issue in this Covid crisis, themselves, not just a family member, but themselves.”

For Sean, there was support, but not in the form of mental health professionals. As an 18-year-old without insurance, he was unlikely to have sought counselling, his mother said.

“Sean’s fast-laned zest for life due to co-existing diagnoses of Attention Deficit Hyperactivity Disorder and Oppositional Defiant Disorder cause him to feel things more deeply that most people and to internalize the most mundane of comments and situations,” Sean’s obituary reads. “Recently, the things of this world became too much, and Satan won his battle for Sean’s mind.”

And because of his rural location, it was unlikely that he would have been able to find anyone with the expertise needed to deal with his previous dual diagnosis, his mother said.

As a child, the family had had to take Sean to a therapist more than an hour away, in Sioux Falls, to deal with his dual diagnosis, Tiede-Webb said.

Talking to a professional, she said, may have made a difference.

“I wouldn’t say that he was any more isolated than before, he still had all of his friends and family that he could talk to and visit any time he wanted,” Tiede-Webb said. “I would say if there was anything at all it would be the fact that he couldn’t work. And I think that was a source of stress for him. You know… to have two jobs and not be able to work either one of them. And he had some pretty big bills to pay.”

Carrie Henning-Smith, Ph.D., a researcher on rural issues with the University of Minnesota School of Public Health, said problems with getting mental health services in rural areas were bad before Covid-19. Now, she said, they’re worse.

Rural residents rely more on their primary physician to provide their mental health care. And with physician’s practices shuttered by Covid-19 restrictions, their main source of treatment may be jeopardized.

“I think it’s important to consider that more than half of rural residents get care for mental health concerns or mental health disorders through a primary care provider,” Henning-Smith said. “And so when we’re talking about bolstering up the mental health care workforce there isn’t a huge mental health care workforce in rural areas. Mental health providers disproportionately work in urban areas… So primary care providers are on the front lines as mental health care providers in rural communities. Unfortunately, they are also on the front lines of Covid and every other issue that’s happening in rural communities right now too.”

Other factors may prevent rural residents from going to get care for their mental health as well, she said. Fear of contracting the coronavirus is one of them.

“So, there’s the pandemic that’s happening right now, and I can completely understand why during a pandemic no one would want to go to a health care facility unless they absolutely had to,” she said. “And so to that extent that people see their own mental health as optional or extra, … I’m afraid sometimes people…  wouldn’t prioritize that and wouldn’t be making time and space for those visits.”

Many providers are switching to telehealth to provide patients with contactless therapy and treatment. But in rural areas, where people may not have access to the internet or the technology required to use telehealth, that may not be a solution either, Hennings-Smith said.

It’s a problem that will likely only get worse as the country reels from the economic damage done by stay-at-home and social distancing orders. Even as states begin to open up again, there is growing concern that it won’t be enough.

According to a recent report from Well Being Trust and the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, the combination of unprecedented economic failure and unemployment, mandated social isolation and uncertainty caused by the coronavirus are exacerbating deaths due to alcohol or drug misuse or due to suicide – deaths of despair.

The report stated that if the U.S. doesn’t invest in solutions to help heal those suffering, the impact of those stressors could result in thousands of additional deaths of despair over the next decade. With a quick economic recovery, where people are back on the job soon, that could be estimated  27,644 deaths over a four-year period. But with a slow recovery, the report estimated as many as 154,037 people could die over the course of 10 years.

The study looked at data from 2018 and what kind of impact unemployment rates had on suicides. It found that a 1%increase in the unemployment rate leads to a 1 to 1.6%increase in suicides.

Researchers think the cost of social distancing and stay-at-home orders will have a bigger impact on rural areas.

“It’s important to note that the underlying causes that drive ‘deaths of despair’ for all in America are multifaceted. They include social and individual-level factors such as isolation and loneliness; systemic issues such as a fractured health care system and lack of culturally and linguistically competent care; and finally community conditions such as systemic racism and structural inequalities in education, income, transportation and housing,” the report said. 

“These are further undergirded by a consistent lack of economic opportunity, stigma, and a combination of opportunity-limiting cultural and environmental factors in communities. Sadly, these factors impact some communities more than other in significant and consequential way, especially in racial and ethnic minority populations, people who are lower-income, or people who live in rural areas.”

The report showed that in places like New Mexico, with an already high rate of deaths of despair of 99 per every 100,000, the highest in the country, a moderate economic recovery in the U.S. could mean an additional 41.2 deaths per every 100,000 people. In fact, most of the counties in the Western half of the U.S. could see increased death rates of between 9.22 and 37.27 cases per every 100,000 people.

Other states, like West Virginia (with 98 deaths per 100,000) and Alaska (with 84.8), could see their deaths of despair increase by more than 30 people per 100,000.

Researchers said the best way to address the issue is with a three-pronged approach – figure out how to address the effects of unemployment, make access to care easier and integrate care the best way possible.

“These are uncertain times, unprecedented. Unfortunately, for too many, this uncertainty may lead to fear, and fear may give way to dread,” said Jack Westfall, MD, MPH, director of the Robert Graham Center. “We try to provide as much certainty as possible to shed some light on our path. We must also make our relationships certain, regardless of the uncertain facts and figures of the day.”

And those in Congress seem to know the stakes. Recently, Rep. John Katko (R-NY) and more than 70 other Congressmen asked Congressional leaders and the Trump administration for additional funding for mental health treatment, especially in rural areas. The letter asked for more than $38 billion in emergency funds to be directed to mental and behavioral health providers in the next Covid-19 relief package.

“In Central New York, many local mental health disorder and addiction treatment providers are being forced to make tough financial decisions as they work to meet an increased need for their services,” said Rep. Katko. “Now more than ever, it is imperative mental health and addiction treatment providers have the resources they need to treat individuals in our community who are struggling with the emotional toll of this crisis.”