Suicide is the 10th leading cause of death in the United States. And, according to CDC data released Oct. 6 in a Morbidity and Mortality Weekly Report,(www.cdc.gov) rural counties had higher suicide rates than metropolitan counties from 2001 to 2015.
For this study, researchers analyzed data from the National Vital Statistics System(www.cdc.gov) that included demographic, geographic and mechanism-of-death information from death certificates filed in all 50 states and the District of Columbia. They specifically examined annual county level trends in suicide rates from 2001 to 2015 using U.S. Census Bureau county population estimates.
Of the more than half a million total suicides that occurred during this period, the breakdown by urbanization level was as follows:
- 256,511 suicides were reported in large metropolitan counties;
- 173,045 were reported in medium/small metropolitan counties; and
- 114,559 were reported in nonmetropolitan/rural counties.
- According to CDC data released Oct. 6 in a Morbidity and Mortality Weekly Report, rural counties had higher suicide rates than metropolitan counties from 2001 to 2015.
- For this study, researchers analyzed data from the National Vital Statistics System that included demographic, geographic and mechanism-of-death information from death certificates filed in all 50 states and the District of Columbia.
- The authors found suicide death rates for rural counties (17.32 per 100,000 people) were higher than those for medium/small metropolitan counties (14.86 per 100,000) and large metropolitan counties (11.92 per 100,000).
According the researchers, those figures translate into suicide death rates for rural counties (17.32 per 100,000 people) that were significantly higher than those for medium/small metropolitan counties (14.86 per 100,000) and large metropolitan counties (11.92 per 100,000).
"While we've seen many causes of death come down in recent years, suicide rates have increased more than 20 percent from 2001 to 2015. And this is especially concerning in rural areas," said CDC Director Brenda Fitzgerald, M.D., in an Oct. 5 news release.(www.cdc.gov) "We need proven prevention efforts to help stop these deaths and the terrible pain and loss they cause."
Regression analyses showed increases in annual age-adjusted suicide rates in all three of these urbanization levels during this timeframe. However, although suicide rates continued to increase in large metropolitan counties during this period, these increases were not significant, said the authors. In nonmetropolitan/rural and medium/small metropolitan counties, suicide rates increased from 2001 to 2007 and accelerated in 2007 and 2008.
The authors noted that the Great Recession from 2007-2009 could have contributed to the spike in suicide rates.
"Economic indicators (e.g., housing foreclosures, poverty and unemployment) vary by urbanization level, with rural areas usually having greater prevalence of these negative factors," the authors said. "Factors such as housing foreclosures and overall business cycles negatively affect suicide rates and other health outcomes. A combination of these factors likely contributed to the differences in annual suicide rate changes by urbanization level observed in this study.
"In addition, because U.S. suicide rates were increasing before the Great Recession, other contributors to the changes in rates were likely."
Additionally, the researchers found that during the study period,
- suicide rates for males were four to five times higher than for females across all urbanization levels;
- suicide rates for black non-Hispanic individuals in rural areas were consistently lower than suicide rates for black non-Hispanic people in urban areas;
- white non-Hispanic individuals have the highest suicide rates in metropolitan counties, and American Indian/Alaska Native non-Hispanic people have the highest rates in rural counties; and
- findings by age group revealed increases in suicide rates for all ages, with the highest rates and greatest rate increases in rural counties.
"The trends in suicide rates by sex, race, ethnicity, age and mechanism that we see in the general population are magnified in rural areas," said James Mercy, Ph.D., director of the CDC's Division of Violence Prevention, in the release. "This report underscores the need for suicide prevention strategies that are tailored specifically for these communities."
To help answer this need, the CDC recently released a suicide prevention technical package(www.cdc.gov) that includes an evidence-based core set of strategies with examples of programs that can be customized to fit the cultural needs of different patients.
Rural Family Physician's Thoughts
Naomi Clancy, M.D., of Morenci, Ariz., recently spoke with AAFP News to offer her perspective on this topic as a family physician practicing in a rural setting and as chair of the AAFP's rural health member interest group.
Describing rural America as "forgotten America," Clancy pointed to significantly reduced economic and social support services in these areas compared with urban centers.
"Levels of poverty are higher in rural America than in urban or suburban America, and isolation is greater -- not only due to decreased population density, but also lack of public transportation," she said.
In addition, access to both primary care and mental health professionals is severely limited in many rural areas, Clancy noted.
"For example, in my community, the nearest adult psychiatrist is an hour away, sees patients only twice a month in that location (as he is traveling from his home office two and a half hours away) and is currently not accepting new patients," she said.
"Most psychiatric care is received from family physicians and mid-levels in my community, and wait times for appointments can be long due to limited numbers of primary care professionals."
Clancy pointed to another factor that she said might play a role in higher rural suicide rates: According to a 2014 study from the Pew Research Center,(www.pewresearch.org) firearm ownership is significantly higher in rural areas, with 51 percent of rural Americans owning a firearm versus 25 percent of urban dwellers and 36 percent of suburban Americans.
That's particularly noteworthy, she said, when one considers that "the majority of suicide attempts with a gun are fatal, compared with a very small percentage of drug overdoses."
Another item to note, Clancy added, is that whether rural, suburban or urban, research is starting to show that social media use is increasing rates of anxiety and depression, which could be factors in rising overall suicide rates.
As to what can be done to improve suicide rates in rural areas, a nationwide focus on improving the economic and social infrastructure of rural America would not only help address factors that lead to suicide, but also improve the lifespan of rural Americans in general, she contended.
Clancy said that in the rural Arizona area where she practices, the community is planning to bring in a mental health professional to speak about suicide prevention at the middle schools. And several of the largest employers in the community are offering employee-assistance programs with free mental health care.
"These employee-assistance programs are actually fairly well utilized by my patients when I encourage them to do so, although many employees are not aware of the program's existence before I bring it up," she said. "However, most patients still have at least a two-hour roundtrip drive for counseling.
"We are also in the process of setting up telecounseling for addiction and, hopefully, will be able to provide telecounseling for other mental health issues, as well."
No matter where they practice, it's important for family physicians to discuss depression, suicide and crisis helplines at every well-child check, as well as during male and female annual exams, Clancy said.
"Our patient-completed review of systems, which is done in the waiting room prior to the visit, includes questions on depression, anxiety, abuse and suicidality," she said. "The National Suicide Prevention Lifeline (1-800-273-8255) can be posted in every exam room and the waiting room, as well."
Related AAFP News Coverage
Leader Voices Blog: A Conversation About Violence as a Public Health Crisis
More From AAFP
Familydoctor.org: Teen Suicide(familydoctor.org)