CDC: Suicide Rates Increase in US Rural Areas

The United States Center for Disease Control (CDC), in a Morbidity and Mortality Weekly Report (MMWR), published a "Surveillance Summary" revealing surprising data that suicide rates are higher in rural areas compared to urban areas.

According to the study, suicide is 1 of the top 10 leading causes of death in the US resulting in 44,193 deaths in 2015 alone. Study data determined that suicide rates are higher in rural areas compared to urban areas, and that the gap in suicide rates between these demographic areas is widening.

The study, led by behavioral scientist Asha Z. Ivey-Stephenson, PhD, and colleagues within the CDC's National Center for Injury Prevention and Control, analyzed data recorded by the National Vital Statistics System (NVSS) between 2001—2015, which included demographic, geographic, and cause of death information derived from death certificates filed in the 50 states and the District of Columbia.

Authors focused on county-level trends of suicide deaths defined by the World Health Organization's (WHO) International Classification of Diseases, 10th Revision (ICD-10). Data were collected from the NVSS's annual compressed mortality data files, which culls data from death certificates in the US, and summarized the 2006 National Center for Health Statistics urban-rural classification scheme for counties — a 6-level classification scheme that identifies levels of urbanization based on population and metropolitan statistical areas. US Census information was used to create county-level population estimates.

Upon analysis, data collected revealed that between 2001—2015, despite an estimated total of 256,511 reported suicides in metropolitan areas and a slight increase in suicide rates between 2005–2015 (following a slight decrease between 2001–2005), large metropolitan counties saw the lowest suicide rates in the study at an estimated 12 persons out of 10,000.

In contrast, the greatest increase in suicide rates occurred in non-metropolitan/rural counties where in 2015 suicide rates were an estimated 20 people out of 10,000.

Ivey-Stephenson and colleagues also reported age, sex, race, and mechanism of death data, indicating suicide rates were higher among persons ≥25 years of age (highest among those 35—64 years of age), 4–5 times higher for males than females, higher for non-Hispanic whites and non-Hispanic American Indian/Alaskan Natives among all counties, and firearms were most often used with rates in nonmetropolitan/rural counties almost double compared to those in large metropolitan and medium/small metropolitan counties.

Suicide numbers are likely underreported, particularly for females and racial/ethnic minorities, which increases likelihood of underestimated statistical data in the final report.

According to Ivey-Stephenson and colleagues, socioeconomic factors may play the largest role in increased suicide rates, remarking that economic indicators (e.g., housing foreclosures, poverty, and unemployment) vary by urbanization level, with rural areas usually having greater prevalence of these negative factors, and factors like housing foreclosures and overall business cycles negatively affect suicide rates and other health outcomes.

The article concludes with a recommendation for public health action, with particular emphasis on rural counties. Ivey-Stephenson suggests further studies are needed to better understand the demographics of suicide and socioeconomic factors associated with suicide, writing that "comprehensive suicide prevention efforts might include leveraging protective factors and providing innovative prevention strategies that increase access to health care and mental health care in rural communities."

CDC Director Brenda Fitzgerald, MD, notes proven prevention efforts are key to helping stop the deaths and the terrible pain caused.

In a press release distributed by the CDC on Oct. 5, Fitzgerald, stated that although data shows many causes of death decreased between 2001—2015, suicide rates increased 21.6%. Fitzgerald noted the increase is especially concerning in rural areas where suicide has become a significant public health problem.

In order to combat the rising suicide rates, the CDC's Division of Violence Prevention released a technical package on suicide prevention, providing resources for communities, policymakers, and health services, like examples of programs that can be tailored to fit the cultural needs of different racial/ethnic groups.

According to Ivey-Stephenson, the technical package on suicide prevention serves as a compilation of an important set of strategies developed using the best available evidence in efforts to provide with the greatest prevention potential.

The US Health Resources and Service administration (HRSA) is also working to develop activities and guidelines for primary care providers based on the data Ivey-Stephenson and colleagues have produced.

Demographic data on trends in suicide “underscore the need to identify protective factors as part of comprehensive suicide prevention efforts, particularly in rural areas," and indicate a need for reevaluation of current suicide prevention programs and a reprioritizing of public health funding and focus.

The CDC's technical package on suicide prevention, informed by collected demographic data on suicide, should serve as a resource guiding and informing prevention decision-making in all communities and states.

Clinicians, policy makers, and communities, have the opportunity to use the data from their study, and guidance from the technical package to target identification of rural communities whose populations are at greatest risk for suicide, and allocate prevention efforts according to identified needs.

"Suicide Trends Among and Within Urbanization Levels by Sex, Race/Ethnicity, Age Group, and Mechanism of Death — United States, 2001—2015" was published October 6, 2017 by the CDC.

The CDC's "Preventing Suicide: A Technical Package of Policy, Programs, and Practices " from lead author Deb Stone, ScD, MSW, MPH, was released in 2017 by the Division of Violence Prevention.