America : Suicide is becoming more common in rural areas

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Suicide is becoming more common in America, an increase most pronounced in rural areas, new research has found.

The study, which appears online today (Sept. 6, 2019) in the journal JAMA Network Open, also highlights a cluster of factors, including lack of insurance and the prevalence of gun shops, that are associated with high suicide rates.

Researchers at The Ohio State University evaluated national suicide data from 1999 to 2016, and provided a county-by-county national picture of the suicide toll among adults.

Suicide rates jumped 41 percent, from a median of 15 per 100,000 county residents in the first part of the study to 21.2 per 100,000 in the last three years of the analysis.

Suicide rates were highest in less-populous counties and in areas where people have lower incomes and fewer resources.

From 2014 through 2016, suicide rates were 17.6 per 100,000 in large metropolitan counties compared with 22 per 100,000 in rural counties.

In urban areas, counties with more gun shops tended to have higher suicide rates.

Counties with the highest suicide rates were mostly in Western states, including Colorado, New Mexico, Utah and Wyoming; in Appalachian states including Kentucky, Virginia and West Virginia; and in the Ozarks, including Arkansas and Missouri.

“While our findings are disheartening, we’re hopeful that they will help guide efforts to support Americans who are struggling, especially in rural areas where suicide has increased the most and the fastest,” said lead researcher Danielle Steelesmith, a postdoctoral fellow at Ohio State’s Wexner Medical Center.

Suicide is so complex, and many factors contribute, but this research helps us understand the toll and some of the potential contributing influences based on geography, and that could drive better efforts to prevent these deaths.”

Suicide rates are trending higher despite a national prevention effort that kicked off in 2015 with the goal of reducing suicide rates 20 percent by 2025.

Another recent analysis found that suicide rates in almost 90 percent of U.S. counties increased more than 20 percent from 2005 to 2015.

The new study included 453,577 suicides by adults 25 to 64 years old from 1996 to 2016. Suicides were most common among men and those 45 to 54 years old.

Suicide prevention can be bolstered with this new information about trends and patterns of suicide, said Cynthia Fontanella, a study co-author and associate professor of psychiatry and behavioral health at Ohio State.

These maps show the increasing rates of suicide and the concentration of suicides in rural counties over time. Credit: Ohio State University

“For example, all communities might benefit from strategies that enhance coping and problem-solving skills, strengthen economic support and identify and support those who are at risk for suicide,” Fontanella said.

“The data showing that suicides were higher in counties with more gun shops – specifically in urban areas – highlights the potential to reduce access to methods of suicide that can increase the chances an at-risk person will die.”

Another factor related to increased suicide rates, particularly in rural areas, was “deprivation,” a cluster of factors including underemployment, poverty and low educational attainment.

Long-term and persistent poverty may be more entrenched and the economic opportunities for individuals more limited in rural areas, Steelesmith said, adding that many rural Americans rely on jobs in agriculture and industries including coal mining.

“In cities, you have a core of services that are much easier to get to in many cases. You may have better access to job assistance, food banks and nonprofits that might all contribute to less desperation among residents,” Steelesmith said.

High social fragmentation – which factors in levels of single-person households, unmarried residents and the impermanence of residents – was associated with higher suicide rates, as was low social capital, a measure of the interconnectedness of people in an area. Both of these were particularly pronounced in rural America.

Other factors associated with higher suicide rates included high percentages of veterans in a county and lower rates of insurance coverage.

Fontanella said that people who live in rural America might particularly benefit from strategies to promote social connections through community engagement activities that offer opportunities for residents to interact and to become familiar with supportive resources in their area.

Steelesmith said it’s important to note that county-by-county geographical information on suicide doesn’t tell the whole story.

Some states, particularly in the West, have large counties with great variability in terms of resident life experiences, for instance. This work also excludes data on suicides by young and elderly Americans.


Suicide is a global public health problem, ranking among the top 20 leading causes of mortality. According to the World Health Organization (WHO), every 40 seconds a life is lost due to self-harm; that accounts for 800,000 deaths per year, 1.4% of total deaths [1].

People younger than 19 are especially susceptible; suicide was the second leading cause of mortality among females and the third among males in the last decade – 6% of all deaths in 2015 (32,499 girls and 34,650 boys) — were caused by suicide, the majority of them via self-harm [23]. As national reports can’t account for all suicides (due to underreporting or misreporting); suicide could be the leading of death worldwide among young people [1].

Suicidal behavior – suicide ideation, planning suicide, attempting suicide, and suicide itself — has the highest rates in low and middle-income countries (LMIC); they account for 75% of youth suicides globally [2]. In America, for instance, 65,000 suicides have been noted per year [4]. A comparison of the last two decades (1990-1999 and 2000–2009) showed the average suicide rate per 100,000 young people in South America increased from 1.04 to 2.32 for boys, and from 1.45 to 2.30 for girls [5]. Guyana, Suriname, and Ecuador have reported the highest rates of suicide in America for girls (Suriname reported the highest rate of suicide for boys only) [56]. Among Andean countries, Ecuador has the second highest suicide rate (7.1 per 100,000 population) after Bolivia (18.7/100,000), and ahead of Colombia (6.1/100,000) and Peru (5.8/100,000).

During the last 15 years, 13,024 suicides were officially reported in Ecuador [7]. Data from the National Institute of Statistics and Census (INEC) indicate that between 1997 and 2016, an average of 191 adolescents died per year [8]. Given the high social stigma associated with suicide, it is likely that current data underestimate actual rates, especially in people younger than 19 years old [4].

Previous studies have looked at the epidemiology of suicide in the Ecuadorian general population [79], but none of them explored the specific trends among teenagers.

The objective of this study is to describe the temporal trend of suicide in adolescents between 10-19 years old, from 1997 to 2016, and to analyze the presence of spatiotemporal clusters of high mortality rates and the spatial distribution due to suicide in adolescents in the country, from 2011 to 2016

RESULTS

3,824 people between 10-19 years committed suicide in Ecuador during the investigated period (1997–2016), out of which 52.3% of deaths occurred in males (n=1,999) and 47.7% in females (n=1,825). There were 4 registered suicide cases for children under 10 years of age in 2015, two suicides in children 8 years old and two suicides in children 9 years old. Stratified by area of residence, 67.1% (n=2,565) lived in urban areas, 29.9% (n=1,144) in rural areas, and 3% (n=115) in unspecified areas. Intentional self-harm by hanging, strangulation, and suffocation represented 52% of all cases (n=1,986). Self-poisoning and exposure to other and unspecified chemicals and noxious substances represented 21.9% of cases (n=840), while self-poisoning and exposure to pesticides represented 17.3% of cases (n = 662). These three ICD-10 codes (X70, X69, and X68, respectively) accounted for 91.2% of suicides (Table ​11).

Table 1

Demographic characteristics and suicide methods in adolescents by sex in Ecuador, 1997-2016.

VariableMalesFemales
10-14 years old n=519 (%)15-19 years old
n=1,480 (%)
10-14 years old
n=451 (%)
15-19 years old
n=1,374 (%)
Area
Urban356 (68.6)1030 (69.6)295 (65.4)884 (64.3)
Rural150 (28.9)413 (27.9)148 (32.8)433 (31.5)
Unspecified13 (2.5)37 (2.5)8 (1.8)57 (4.1)
Region
Coast129 (24.9)444 (30.0)123 (27.3)338 (24.6)
Highlands361 (69.5)891 (60.2)299 (66.3)900 (65.5)
Amazon29 (5.6)142 (9.6)28 (6.2)135 (9.8)
Galapágos Islands0 (0.0)3 (0.2)1 (0.2)1 (0.1)
Suicide method
Poisoning:
     – Pesticides18 (3.5)192 (13.0)79 (17.5)373 (27.1)
     – Other unspecified chemicals and noxious substances35 (6.7)240 (16.2)114 (25.3)451 (32.8)
     – Others substances*1(0.2)23 (1.6)5 (1.1)30 (2.2)
Hanging, strangulation and suffocation436 (84.0)868 (58.4)228 (50.6)457 (33.3)
Drowning and submersion5 (1.0)10 (0.7)4 (0.9)1 (0.1)
Firearm20 (3.9)110 (7.6)8 (1.8)36 (2.6)
Explosive material0 (0.0)1 (0.1)0 (0.0)0 (0.0)
Smoke, fire and flames0 (0.0)0 (0.0)0 (0.0)1 (0.1)
Sharp object0(0.0)3 (0.2)0 (0.0)0 (0.0)
Jumping from a high place0(0.0)7 (0.5)1 (0.2)2 (0.1)
Unspecified means4 (0.8)26 (1.8)12 (2.7)23 (1.7)

* Includes groups of ICD 10 codes: X60, X61, X62, X63, X64, X65, X66 and X67

We did not find significant differences between the monthly distribution of suicides and sex (p=0.14).

*-*-*-*-

Suicide rates in Michigan have increased by a third in the last 19 years, according to  research published Thursday by the US Centers for Disease Control and Prevention .

According to the study, Michigan has seen a 32.9 percent increase in suicides since 1999. 

Twenty-five states experienced a rise in suicides by more than 30%, the government report finds. Across the nation, suicide rates are up 25 percent in that same time period.

More than half of those who died by suicide had not been diagnosed with a mental health condition, said Dr. Anne Schuchat, principal deputy director of the CDC.

“These findings are disturbing. Suicide is one of the top 10 causes of death in the US right now, and it’s one of three causes that is actually increasing recently, so we do consider it a public health problem — and something that is all around us,” Schuchat said. The other two top 10 causes of death that are on the rise are Alzheimer’s disease and drug overdoses, she noted.

In 2016 alone, about 45,000 lives were lost to suicide.

“Our data show that the problem is getting worse,” Schuchat said.

Increases in 49 states

Using data from the National Vital Statistics System for 50 states and the District of Columbia, CDC researchers analyzed suicide rates for people 10 and older from 1999 through 2016.

Overall, the US experienced a 25% rise in the rate of suicides during that period, with individual states ranging from a 6% increase in Delaware to a nearly 58% increase in North Dakota, the researchers say.

All states except Nevada experienced an increase; although Nevada showed a 1% decrease in suicide, the state’s suicide rate was still high, ranging between 21 and 23 suicides for every 100,000 people through the years studied, the researchers say.

Suicide rates were four times greater in the highest state compared with the lowest when calculated on an annual basis during the most recent time period, 2014 to 2016.

Montana experienced about 29 suicides for every 100,000 people — the highest in the nation — compared with about seven people out of every 100,000 in the District of Columbia — the lowest. As a whole, the nation saw 15 people dying by suicide for every 100,000 in 2016.

“The most common method was firearm, followed by hanging or suffocation, followed by poisoning,” Schuchat said. “Opioids were present in 31% of individuals who died by poisoning.” She added that intentionality is difficult to determine in cases in which a person dies by overdose.

Deborah Stone, lead author of the study and a behavioral scientist at the CDC, said Thursday, “We typically see that firearms make up about half of all suicides, and that tends to be pretty consistent.”

Schuchat noted that the researchers “focused in on 27 states where we have extensive data from the death investigations to try to understand the factors or circumstances leading up to suicide.”

These data, derived from the National Violent Death Reporting System, showed that 54% of those who committed suicide in 2015 did not have a known mental health condition. Digging deeper, the researchers found that several circumstances, including the loss of (or problems in) a relationship, were more likely to trigger a suicide among those who did not have a mental health condition.

Regions and demographic groups were also compared.

Economic factors behind suicide

The Western area trend of high increases in suicide rates could be related to the fact that people in rural areas have less access to services as they more slowly benefit from the economic recovery than other parts of the nation, she said.

“We don’t have all the answers. There may be several, but we knew that economic factors can increase the risk of suicide and that limited access to care, behavioral and social services may also increase the risk of suicide,” Schuchat said.

Recent government reports have highlighted rising rates of suicide among women. “The percent increase was higher in women, but it’s important to say that men have a three to five times higher rate than women,” Schuchat said. The rising suicide rate for women, then, is “increasing but at a much, much lower level” than for men.

Veterans are also “overrepresented” in the report, she said.

“Veterans made up about 18% of adult suicides but represent about 8.5% of the US adult population,” Schuchat said, noting that not all veterans who died by suicide were recent veterans. Still, the researchers found a 10% higher risk of suicide among people who had served in the military.

Middle-age adults had the highest increase.

“This is a very important population right now in terms of national statistics,” Schuchat said, noting the high rates of drug overdose in this group as well as “deaths of despair” described in social science literature. She believes this group may have been hardest-hit by the economic downturn, but she added that unknown factors probably contributed.

“We think a key message is, there’s not just one group; many are at risk,” Schuchat said.

Whether or not they had a mental health condition, most people who died by suicide had experienced “one or more factors that may have contributed, including a relationship problem, a crisis in the recent couple weeks and problematic substance abuse,” she said.

‘Alarming’

K. Bryant Smalley, a professor of community medicine and psychiatry at the Mercer University School of Medicine, described the mental health care challenges experienced by patients in rural areas as the “three A’s”: availability, accessibility and acceptability of care.

Smalley, who was not involved in the new research, pointed out that about 85% of federally designated mental health professional shortage areas are rural.

“Due to higher poverty rates, higher likelihood of hourly pay and productivity-based labor, and lack of transportation infrastructure, mental health services are often not accessible even if they are available in a rural community — that is, even though it is there, many people either cannot get to it or cannot afford (either directly or indirectly) to go,” he said.

Add to that, rural areas have very high levels of stigma surrounding mental health services. “Rural residents face lower levels of anonymity in seeking services due to the close-knit nature of rural communities,” Smalley said. The possibility of “someone seeing your car parked at the only psychologist’s office” means rural residents are less likely to seek care when needed.

Dr. Sandro Galea, dean and Robert A. Knox Professor at the Boston University School of Public Health, said the National Vital Statistics System is the “best system we have of keeping records in the country.” Galea, who was not involved in the new study, added that for this reason, the new research should be taken “very seriously.”

“There have been previous reports recently that have shown suicide is one of the major contributors to a decrease in life expectancy in this country, which makes it even more alarming,” he said.

“The paper makes a clear case, correctly, about the fact that there is no one cause for suicide,” he said, adding that “availability of means” makes death possible.

“A lot of suicide is a one-time effort, so having guns available, for example, makes one more likely to complete suicide, but that in and of itself is not an explanation for why suicide is going up,” Galea said.

“CDC data shows that suicide happens to everybody,” he said. “Social and life and economic stressors are the ones that create the conditions for suicides to happen.”

If you feel extreme distress, you can call 1-800-273-8255, the National Suicide Prevention Lifeline, to speak with someone who will provide free and confidential support 24 hours a day, seven days a week. If you want to learn how to help someone in crisis, you can call the same number.

The CDC also recommends its own policies, programs and practices for prevention.

Shuchat said there are simple steps anyone can take to help someone at risk. “Beginning a conversation, helping keep them safe, helping them connect and then follow up with them,” she said. “We don’t think every single suicide can be prevented, but many are preventable.”


More information:JAMA Network Open (2019). DOI: 10.1001/jamanetworkopen.2019.10936

Journal information: JAMA Network Open
Provided by The Ohio State University

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