Suicide rates have risen dramatically around the entire world in the last two decades, and the United States is no exception. Some parts of the country are experiencing a more rapid rise than others, though. Fortunately, new research in JAMA Network Open provides a clearer idea of what’s going wrong.
In a paper published on Friday, a team of researchers concluded that suicide rates in rural US counties are rising faster than those in the rest of the country. By combing through data on US suicides of adults between age 25 and 64 from 1999 through 2016, they identified the four factors that may be most responsible for this marked difference between rural and metropolitan areas: easy access to firearms, a lack of social connectedness, fewer opportunities for civic engagement, and a lack of health insurance.
The authors, led by Danielle L. Steelesmith, Ph.D., who completed the work as a Ph.D. student at Ohio State University, write that individuals who live in rural counties are especially likely to face “the effects of deprivation, such as lower levels of education, employment, and household income.”
“Long-term and persistent poverty appears to be more entrenched and economic opportunities more constrained in rural areas,” they continue. “Greater social isolation, challenges related to transportation and interpersonal communication, and associated difficulties accessing health and mental health services likely contribute to the disproportionate association of deprivation with suicide in rural counties.”
Amid this complex picture of economic and social hardship, four key factors of special concern arose. Here’s why each one matters:
4. Proximity to Gun Stores
In all counties except for the very most rural ones, proximity to a gun shop was associated with a significantly higher risk of suicide. This effect held true for larger cities, too.
There’s been much debate lately over how gun ownership interacts with suicide rates. On the one hand, gun rights supporters have advocated an approach that emphasizes proper storage to prevent suicides, and indeed, there is a significant association among military service members between unsafe gun storage and higher suicide rates.
But on the other hand, as this latest research shows, in most US counties, access to guns had a significant positive association with suicide rates, without accounting for storage methods.
3. Lack of Social Connectedness
This paper revealed a significant connection between social fragmentation and suicide rates. In other words, the fewer social connections people had, the more likely they were to die from suicide.
To measure this, the team created a social interaction index that accounts for a handful of factors that contribute to a lack of social connectedness: “single-person households, percentage of unmarried residents, renter-occupied housing units, and residents who have moved within a year.”
While the solutions to this problem aren’t immediately clear, what is clear is that social connections are important to building a life that feels worth living. As previous research has shown, loneliness is a major driving factor in increasing rates of mental illness among millennials, and this latest study suggests that effect could exist among older adults, too.
2. Few Civic Opportunities
Similar to social disconnectedness, a lack of civic opportunities was significantly correlated with rising suicide rates in the US. This factors is a little different from social connectedness in that it’s more about being an engaged citizen than simply having friends and associations.
Especially in rural areas, there may not be local government, social clubs, religious communities, volunteer groups, or other opportunities for individuals to feel a part of a society.
1. Low Rates of Health Insurance Coverage
Last but certainly not least, a lack of health insurance coverage is significantly associated with rising suicide rates in rural US counties.
Specifically, the researchers observed that the more people in a county who didn’t have health insurance coverage, the higher that county’s suicide rate was.
“This finding is consistent with results of previous studies that associate health insurance coverage with increased mental health treatment and lower suicide rates and suggests that improving insurance coverage and mental health parity laws may be associated with reduced risks within a community and lower suicide rates,” they write.
Small Steps Toward Solutions
Taken altogether, these findings contribute to a growing sense of the US’s problem with so-called “deaths of despair.” Often associated with opioid overdose deaths, this category also encompasses suicides, and researchers are increasingly understanding that these public health crises share some underlying factors: social isolation, lack of healthcare, and poverty, all of which contribute to poor mental health outcomes and sometimes early death.
As a country, this new research adds to that picture not just by showing how bad things are, but by pointing to some specific areas in which we could do better. It’s a small step, but an important one nonetheless.
Results: Between 1999 and 2016, 453 577 individuals aged 25 to 64 years died by suicide in the United States. Decedents were primarily male (349 082 [77.0%]) with 101 312 (22.3%) aged 25 to 34 years, 120 157 (26.5%) aged 35 to 44 years, 136 377 (30.1%) aged 45 to 54 years, and 95 771 (21.1%) aged 55 to 64 years. Suicide rates were higher and increased more rapidly in rural than in large metropolitan counties. The highest deprivation quartile was associated with higher suicide rates compared with the lowest deprivation quartile, especially in rural areas, although this association declined during the period studied (rural, 1999-2001: incidence rate ratio [IRR], 1.438; 95% CI, 1.319-1.568; P < .001; large metropolitan, 1999-2001: 1.208; 95% CI, 1.149-1.270; P < .001; rural, 2014-2016: IRR, 1.121; 95% CI, 1.032-1.219; P = .01; large metropolitan, 2014-2016: IRR, 0.942; 95% CI, 0.887-1.001; P = .06). The presence of more gun shops was associated with an increase in countylevel suicide rates in all county types except the most rural (rural: IRR, 1.001; 95% CI, 0.999-1.004; P = .40; micropolitan: IRR, 1.005; 95% CI, 1.002-1.007; P < .001; small metropolitan: IRR, 1.010; 95% CI, 1.006-1.014; P < .001; large metropolitan: IRR, 1.012; 95% CI, 1.006-1.018; P < .001). High social capital was associated with lower suicide rates than low social capital (IRR, 0.917; 95% CI, 0.891-0.943; P < .001). High social fragmentation, an increasing percentage of the population without health insurance, and an increasing percentage of veterans in a county were associated with higher suicide rates (high social fragmentation: IRR, 1.077; 95% CI, 1.050-1.103; P < .001; percentage of population without health insurance: IRR, 1.005; 95% CI, 1.004-1.006; P < .001; percentage of veterans: IRR, 1.025; 95% CI, 1.021-1.028; P < .001).
Conclusions and Relevance: This study found that suicide rates have increased across the nation and most rapidly in rural counties, which may be more sensitive to the impact of social deprivation than more metropolitan counties. Improving social connectedness, civic opportunities, and health insurance coverage as well as limiting access to lethal means have the potential to reduce suicide rates across the rural-urban continuum.