From the Journals

New study confirms rise in U.S. suicide rates, particularly in rural areas

County-by-county analysis cites links to higher density of gun shops, other factors



Suicide rates in the United States climbed from 1999 to 2016, a new cross-sectional study found, and the increases were highest in rural areas.

“These findings are consistent with previous studies demonstrating higher and more rapidly increasing suicide rates in rural areas and are of considerable interest in light of the work by [Anne] Case and [Angus] Deaton,” wrote Danielle L. Steelesmith, PhD, and associates. “While increasing rates of suicide are well documented, little is known about contextual factors associated with county-level suicide rates.” The findings appear in JAMA Network Open.

To examine those contextual factors, Dr. Steelesmith, of the department of psychiatry and behavioral health at the Ohio State University, Columbus, and associates analyzed county-by-county suicide statistics from 1999 to 2016 for adults aged 25-64 years, noting that they “focused on this age range because most studies on mortality trends have focused on this age range.”

The researchers developed 3-year suicide averages for counties for rate “stabilization” purposes. They placed the counties into four categories (large metropolitan, small metropolitan, micropolitan, and rural), and used various data sources to gather various types of statistics about the communities.

The study reported that 453,577 suicides within the 25-64–year age group occurred from 1999 to 2016. Most of those who died by suicide were men (77%), and most (51%) were aged 45-64 years. The median suicide rate per county rose from 15 per 100,000 (1999-2001) to 21 per 100,000 (2014-2016), reported Dr. Steelesmith and associates.

Rural counties only made up 2% of the suicides, compared with 81% in large and small metropolitan counties, but suicide rates were “increasing most rapidly in rural areas, although all county types saw increases during the period studied,” Dr. Steelesmith and associates wrote.

They added that “counties with the highest excess risk of suicide tended to be in Western states (e.g., Colorado, New Mexico, Utah, and Wyoming), Appalachia (e.g., Kentucky, Virginia, and West Virginia), and the Ozarks (e.g., Arkansas and Missouri).”

In addition to the connections between increasing suicide rates, living in a rural area, and a higher density of gun shops, the researchers cited other contextual factors. Among those factors were higher median age and higher percentages of non-Hispanic whites, numbers of residents without health insurance, and veterans. They also found links between higher suicide rates and worse numbers on indexes designed to measure social capital; social fragmentation; and deprivation, a measure encompassing lower education, employment levels, and income.

“Long-term and persistent poverty appears to be more entrenched and economic opportunities more constrained in rural areas,” Dr. Steelesmith and associates wrote. “Greater social isolation, challenges related to transportation and interpersonal communication, and associated difficulties accessing health and mental health services likely contribute to the disproportionate association of deprivation with suicide in rural counties.”

Dr. Steelesmith and associates cited several limitations. One key limitation is that, because the study looked only at adults aged 25-64 years, the results might not be generalizable to youth or elderly adults.

No study funding was reported. One study author reported serving on the scientific advisory board of Clarigent Health and receiving grant support from the National Institute of Mental Health outside of the submitted work. No other disclosures were reported.

SOURCE: Steelesmith DL et al. JAMA Netw Open. 2019 Sep 6. doi: 10.1001/jamanetworkopen.2019.10936.

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