Wednesday, March 11, 2015

Suicide In Rural America: Isolation, Stigma and Firearms

Have you ever lived in a rural community?
Rural America can be simultaneously beautiful and isolating.


You might find this to be an unusual question. Have you ever lived in a rural community? Based on the 2010 census only 19.3% of the U.S. population lived in rural areas, while 80.7% of the population resided in urban areas. So if you live in a rural community, you are in the minority. We recently asked an associate if she had ever lived in a rural community and we were surprised to learn she had indeed. She offered the following observations:
I lived in small village in New Hampshire. The last census data for 2010 indicated that the village had 294 residents. Of course, this was one of six villages that were part of one town. So the entire town had a combined population of 10,115 in 2010. There was no airport, train service, local bus service, interstate freeway or highway, and only one bus per day stopped to pick up travelers going north or south. We had a regional middle school and high school, one community hospital that could handle basic services; however, any major medical condition would require patients being medevacked to a major medical center. We had one pediatrician, and at that time maybe one psychiatrist. We had volunteer firemen. There were no local colleges or universities. We were, for all intents and purposes, isolated. And it was often lonely.

How living in a rural community may affect suicide rates


This week the results of a new research study were published online in JAMA Pediatrics: Widening Rural-Urban Disparities in Youth Suicides, United States, 1996-2010. The lead author was Cynthia Fontanella, Ph.D. Department of Psychiatry and Behavioral Health, The Ohio State University (OSU) Wexner Medical Center. The research team consisted of professionals from the College of Social Work at OSU, the Center for Biostatistics at OSU, Department of Pediatrics at OSU, Center for Innovation in Pediatric Practice, and the Bureau of Research and Evaluation Ohio Department of Mental Health and Addiction Services Columbus, Ohio. This was a longitudinal study to examine trends in US suicide mortality for adolescents and young adults across the rural-urban continuum.

Study's parameters


  • The data reviewed spanned from January 1, 1996 through December 31, 2010
  • Reseachers reviewed county-level national mortality data from 3141 counties 
  • The studied population was suicide decedents from 10 to 24 years of age
  • The total number of suicides was 66,595

Study's findings


Previous studies have indicated that both adults and adolescents have a higher risk of suicide in more remote rural areas, but it is important to note that the Centers for Disease Control (CDC) reports the third leading cause of death for people 15 to 24 years of age is suicide and the second leading cause of death for those age 25 to 34. If you look at the population as a whole, then suicide is the 10th most common cause of death. 

According to this research study:

  • Rural suicide rates were nearly double those of urban areas for both males (19.93 and 10.31 per 100 000, respectively) and females (4.40 and 2.39 per 100 000, respectively). 
  • Even after controlling for a wide array of county-level variables, rural-urban suicide differentials increased over time for males, suggesting widening rural-urban disparities (1996-1998: adjusted incidence rate ratio [IRR], 0.98; 2008-2010: adjusted IRR, 1.19; difference in IRR, P = .02). 
  • Firearm suicide rates declined, and the rates of hanging/suffocation for both males and females increased. 
  • However, the rates of suicide by firearm (males: 1996-1998, 2.05; and 2008-2010: 2.69 times higher) and hanging/suffocation (males: 1996-1998, 1.24; and 2008-2010: 1.63 times higher) were disproportionately higher in rural areas, and rural-urban differences increased over time (P = .002 for males; P = .06 for females). 

Some conversation starters...


While for many these results may be startling, for many they could have been predicted. Over the years we have often posted about suicide, in fact, it was just about two years ago that we reported on a study that discussed how many suicidal adolescents and young adults have easy access to firearms. But it is not all about access to firearms, as Dr. Fontanella shared with The Atlantic:
“Rural residents often grow up with guns, have guns in their homes and there’s just a general culture of guns in rural areas,” Fontanella says. Even so, she says, suicide rates by all methods were higher in the country [rural] than in the city. The factors that might contribute to this disparity make a snarled web of many threads. Gun access is just one of those. Rural life is isolating—and getting more so...And these areas continue to lose population. Plus, “a lot of young people are out-migrating because of the lack of employment opportunities,” Fontanella says, “which can lead to heightened degrees of social isolation for those left behind.”

So what becomes of those left behind? Few resources of every kind, few mental health resources and people of all ages fear the stigma of seeking help for mental health issues. The starting point is to have a conversation with your family, reach out to your primary care provider...don't be afraid to start the conversation. It could be a life saver.

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