Suicide Rates Higher in Rural Than in Urban Youth

A large review of national data indicates that suicide rates for adolescents and young adults appear to be higher in rural communities than in urban communities, regardless of the method, a disparity that seems to be increasing over time.

The analysis of nearly 67,000 suicides occurring between 1996 and 2010 among youths aged 10 to 24 found that the two times higher rate of suicide in rural versus urban areas was present among both genders. For males, the rural suicide rate was 19.93 per 100,000, compared with a rate of 10.31 per 100,000 observed in youth residing in urban areas. For females, the respective rates were 4.40 and 2.39 per 100,000.

Published in JAMA Pediatrics, the study also found that although male suicide rates decreased significantly over time in urban areas, female suicide rates increased over time in the must rural and most urban areas.

Whereas firearm use decreased as the means of suicide over the study period, the rates of hanging or suffocation increased for both males and females. The rates of suicide by firearm and hanging or suffocation were disproportionately higher in rural areas than in urban areas, a difference than increased over time. Overall, firearm was the most common means of suicide during the study period (51.1%), followed by hanging (33.9%), poisoning (7.9%), and other methods that included jumping and transportation-related suicide (7.1%).

“These kinds of surveillance studies can really help us identify areas to target our prevention efforts, and it's clear we need to target rural areas for primary prevention of suicide,” said lead study author Cynthia A. Fontanella, PhD, clinical assistant professor of psychiatry and behavioral health at The Ohio State University Wexner Medical Center.

Dr. Fontanella and colleagues suggest several possible explanations for the trends observed in their study, perhaps most importantly the limited availability and accessibility of mental health services in rural areas. Of the 1,669 areas federally designated as experiencing a shortage of mental health professionals, more than 85% are in rural areas.

What’s more, more than half of all the counties in the United States—all of which are rural—have no practicing psychiatrist, psychologist, or social worker, shortages that are worse for pediatric mental health specialists, according to previous research. Rural Americans also have lower family incomes and are less likely than urban Americans to have healthcare with mental health benefits. “Rural America is beautiful, and many individuals live in close-knit communities,” said Dr. Fontanella. “But in terms of access to services and perhaps some other factors, the cards may be stacked against them.”

Geographic and social isolation may also play a role in the trends observed in the study, according to the authors. “The lower population density and wide geography characteristic of rural areas are potentially socially isolating, with less face-to face contact with family, friends, and other support networks,” they write. “Associated feelings of loneliness and depression could contribute to suicidal behavior.”

The study authors also cite access to lethal means as another possible factor in the observed trends. Owning and using firearms has been shown to be more common in rural areas because of their use for hunting, agricultural needs, recreation, and for cultural reasons. Data also indicate that gun ownership is declining in urban areas, while remaining stable in rural areas.

Sociodemographic and economic factors are suggested by Fontanella and colleagues as a potential reason for the rural—urban suicide disparity observed in the study. Dwindling populations in nearly half of nonmetropolitan counties and a greater hit by the “great recession” in rural than in urban communities can lead to greater feelings of hopelessness, depression, isolation, and substance abuse, all of which are risk factors for suicide.

To combat the rural—urban disparities in suicide, the study team suggests integrated care services, the use of telemedicine, and school-based interventions as community structural factors that affect access to and the availability and acceptability of mental health services. Senior author, John V. Campo, MD, chair of psychiatry and behavioral health at Wexner Medical Center, suggested that “Because families living in rural areas tend to see a primary care practitioner for most of their health care, integrating mental health care into rural primary care settings—either with on-site practitioners or via remote video access—has promise…It's going to be hard to generate the numbers of mental-health providers to get where we need to go. So we need to address things qualitatively to improve the entire system of care, which will improve access.”