Rural suicides in the U.S. have climbed significantly in recent years, and farm leaders and mental health care providers say the financial toll of President Donald Trump’s trade war could contribute to the tragedy.

An official of the National Farmers Union warned earlier this year that financial stress, including the added burden of disappearing markets in the trade war, appear to be taking a toll on farmers’ mental health.

“It’s been insane,” Patty Edelburg, vice president of the organization that represents some 200,000 families, said on Fox News in May. “We’ve had a lot more bankruptcies going on, a lot more farmer suicides.”

She said the trade war with China could contribute to financial stress.

“We have more commodities, more grain sitting on the ground right now because we lost huge export markets,” she said. “We’ve lost export markets that we’ve had for 30 years that we’ll never get a chance to get back again.”

A new survey published this month in JAMA Network Open covering the years from 1999 to 2016, leading up to when Trump took office, found that the rate of suicide among Americans ages 25 to 64 rose by 41% in that time. Rates among those living in rural counties were 25% higher than people in major metropolitan areas.

Researchers suspect the increase is related to poverty, lower incomes and underemployment. “Those factors are really bad in rural areas,” study author Danielle Steelesmith, a postdoctoral fellow at Ohio State University’s Wexner Medical Center, told NBC.

The study also found that counties with high levels of social fragmentation — based on the levels of single-person households, unmarried residents and transient residents — and a high percentage of veterans had higher rates of suicide. All of those factors were more pronounced in rural counties.

And farmers have voiced concern that Trump’s trade war could exacerbate tough financial conditions for them.

“With these added tariffs, farmers are not getting their [credit] lines renewed, banks are coming in and foreclosing on their farms, taking their family living away, and it’s too much for some of them,” Minnesota soybean farmer Bill Gordon told CNN earlier this year. “We have seen a definite increase in the suicide rate and depression in farmers in the U.S.”

Wisconsin had a record 915 suicides in 2017, many of them farmers under financial stress. Net farm income has plunged 50% in six years.

Farm help organization Farm Aid reported a 30% increase last year in calls to its hotline.

The calls and “our work with partners around the country confirm that farmers are under incredible financial, legal and emotional stress. Bankruptcies, foreclosures, depression and even suicide are some of the tragic consequences of these pressures,” said a statement from the organization.

“America’s family farmers — reduced in numbers since the farm crisis of the 1980s — have approached endangered status. ... At Farm Aid, we spend our time on the phone with anxious farm families who cannot make ends meet, and who will not be able to improve their situation simply by working harder. Confusion and lack of resolution on policies like trade, immigration and healthcare accelerate the crisis.”

Mike Rosmann, a therapist who helps suicidal farmers, blames the stresses of surviving on the land for farmers who can’t take it anymore. Low farm prices, the “prolonged recession in agriculture,” flooding and the Trump administration are all causing problems, he wrote in an April column in The New Republic. “Farmers are becoming dismayed about the tariffs.”

A Morning Consult and American Farm Bureau Federation research poll published in April found that 91% of farmers and farmworkers said financial issues are affecting their mental health. About 87% of those surveyed said they fear losing their farms.

Clarification: This article has been updated to note the statistics about suicides that are available are from the years before Trump’s recent trade war, though farmers and farm advocates are concerned more recent tariffs will exacerbate the toll on farmers’ mental health.

CORRECTION: An earlier version of this article referred to a piece by Matt Rossman in The New Republic. The column was by Mike Rosmann.