A longitudinal examination of rural status and suicide risk

Help-seeking behavior among adults who attempted or died by suicide in Ontario, Canada

INTRODUCTION

This study aims to determine the relationship between rurality and help-seeking behavior prior to a suicide or suicide attempt.

METHODS

Data from 2007 to 2017 were obtained from administrative databases held at ICES, which capture all hospital, emergency department (ED), and general practitioner (GP) visits across Ontario. Rurality was defined using the Rurality Index of Ontario scores. Help-seeking was based on accessing health services 1 year prior to the event.

RESULTS

Among those who died by suicide (N = 9848), those living in rural areas were less likely to seek help from a psychiatrist (rural males: AOR = 0.42, 95% CI = 0.31-0.57; rural females: AOR = 0.46, 95% CI = 0.29-0.97) compared with those living in urban areas. We found a similar association among those who attempted suicide (N = 82,480) (rural males: AOR = 0.49, 95% CI = 0.43-0.56; rural females: AOR = 0.51, 95% CI = 0.46-0.57). Rural males and females were more likely to seek care from an ED for mental health reasons compared with urban males and females.

CONCLUSIONS

Among people who died by suicide, those living in rural areas are generally less likely to access psychiatrists and GPs and more likely to access EDs, suggesting that people living in rural areas may have less access to care than their urban counterparts.

Rurality as a Risk Factor for Attempted Suicide and Death by Suicide in Ontario, Canada

OBJECTIVE

This study aims to examine rural and urban differences in attempted suicide and death by suicide in Ontario, Canada.

METHOD

This is a population-based nested case-control study. Data were obtained from administrative databases held at ICES, which capture all hospital and emergency department visits across Ontario between 2007 and 2017. All adults living in Ontario who attempted suicide or died by suicide are included in the study, and controls were matched by sex and age. Suicides were captured using vital statistics. Suicide attempts were determined using emergency department service codes.

RESULTS

Rurality is a risk factor for attempted suicide and death by suicide. Rural males are more likely to die by suicide compared with urban males (adjusted odds ratio(AOR) = 1.70, 95% confidence interval (CI), 1.49 to 1.95), and the odds of death by suicide increase with increasing levels of rurality. Rural males and females have an increased risk of attempted suicide compared with their urban counterparts (males: AOR = 1.37, 95% CI, 1.24 to 1.50) (females: AOR = 1.26, 95% CI,  1.14 to 1.39), with a pattern of increasing risk of suicide attempts with increasing rurality. Rural females are not at increased risk of suicide compared with urban females (AOR = 1.08, 95% CI, 0.80 to 1.45). Sensitivity analyses corroborated the results.

CONCLUSIONS

Rural males are almost two times more likely to die by suicide compared with urban males, and both rural males and females have an elevated risk of suicide attempts compared with urban residents. Future research should examine potential mediators of the relationship between rurality and suicide.

Factors Associated With Hospital Presentation of Self-Harm Among Older Canadians in Long-Term Care: A 12-Year Cohort Study

OBJECTIVES

This study aimed to examine the incidence of, and factors associated with, hospital presentation for self-harm among older Canadians in long-term care (LTC).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

The LTC data were collected using Resident Assessment Instrument-Minimum Data Set (RAI-MDS) and Resident Assessment Instrument-Home Care (RAI-HC), and linked to the Discharge Abstract Database (DAD) with hospital records of self-harm diagnosis. Adults aged 60+ at first assessment between April 1, 2003, and March 31, 2015, were included.

METHODS

Adjusted hazard ratios (HRs) of self-harm for potentially relevant factors, including demographic, clinical, and psychosocial characteristics, were calculated using Fine & Gray competing risk models.

RESULTS

Records were collated of 465,870 people in long-term care facilities (LTCF), and 773,855 people receiving home care (HC). Self-harm incidence per 100,000 person-years was 20.76 [95% confidence interval (CI) 20.31-25.40] for LTCF and 46.64 (44.24-49.12) for HC. In LTCF, the strongest risks were younger age (60-74 years vs 90+: HR, 6.00; 95% CI, 3.24-11.12), psychiatric disorders (bipolar disorder: 3.46; 2.32-5.16; schizophrenia: 2.31; 1.47-3.62; depression: 2.29; 1.80-2.92), daily severe pain (2.01; 1.30-3.11), and daily tobacco consumption (1.78; 1.29-2.45). For those receiving HC, the strongest risk factors were younger age (60-74 years vs 90+: 2.54; 1.97-3.28), psychiatric disorders (2.20; 1.93-2.50), daily tobacco consumption (2.08; 1.81-2.39), and frequent falls (1.98; 1.46-2.68). All model interactions between setting and factors were significant.

CONCLUSIONS AND IMPLICATIONS

There was lower incidence of hospital presentation for self-harm for LTCF residents than HC recipients. We found sizable risks of self-harm associated with several modifiable risk factors, some of which can be directly addressed by better treatment and care (psychiatric disorders and pain), whereas others require through more complex interventions that target underlying factors and causes (tobacco and falls). The findings highlight a need for setting- and risk-specific prevention strategies to address self-harm in the older populations.

Rurality and Risk of Suicide Attempts and Death by Suicide among People Living in Four English-speaking High-income Countries: A Systematic Review and Meta-analysis

OBJECTIVE

Previous research indicates a potential relationship between rurality and suicide, indicating that those living in rural areas may be at increased risk of suicide. This relationship has not been reviewed systematically. This study aims to determine whether those living in rural areas are more likely to complete or attempt suicide.

METHOD

This systematic review and meta-analysis included observational studies based on people living in Canada, the United States, the United Kingdom, and Australia. Data sources included PubMed, EMBASE, PsycINFO, and Google Scholar from January 2006 to December 2017. Studies must have compared rural and urban suicide or suicide attempts. Nonprimary research articles were excluded.

RESULTS

A total of 6,259 studies were identified and 53 were included. Results indicate that males living in rural areas are more likely to complete suicide than their urban counterparts (RR = 1.41, 95% CI, 1.21 to 1.64, I² = 96%). Females in rural areas are not significantly more likely to complete suicide (RR = 1.16, 95% CI, 0.98 to 1.37, I² = 79%). Among studies that only reported combined estimates, rural individuals are more likely to complete suicide (RR = 1.22, 95% CI, 1.11 to 1.33, I² = 98%). There is no association found between rurality and suicide attempts (RR = 0.93, 95% CI, 0.73 to 1.19, I² = 85%).

CONCLUSIONS

Those living in rural areas are more likely to complete suicide, with some studies indicating that only rural males are more likely to complete suicide; these findings are relatively consistent across all four countries. Public health initiatives should aim to overcome geographic variation in completed suicide, with a particular focus on rural males.

The interRAI Suite of Mental Health Assessment Instruments: An Integrated System for the Continuum of Care

The lives of persons living with mental illness are affected by psychological, biological, social, economic, and environmental factors over the life course. It is therefore unlikely that simple preventive strategies, clinical treatments, therapeutic interventions, or policy options will succeed as singular solutions for the challenges of mental illness. Persons living with mental illness receive services and supports in multiple settings across the health care continuum that are often fragmented, uncoordinated, and inadequately responsive. Appropriate assessment is an important tool that health systems must deploy to respond to the strengths, preferences, and needs of persons with mental illness. However, standard approaches are often focused on measurement of psychiatric symptoms without taking a broader perspective to address issues like growth, development, and aging; physical health and disability; social relationships; economic resources; housing; substance use; involvement with criminal justice; stigma; and recovery. Using conglomerations of instruments to cover more domains is impractical, inconsistent, and incomplete while posing considerable assessment burden. interRAI mental health instruments were developed by a network of over 100 researchers, clinicians, and policy experts from over 35 nations. This includes assessment systems for adults in inpatient psychiatry, community mental health, emergency departments, mobile crisis teams, and long-term care settings, as well as a screening system for police officers. A similar set of instruments is available for child/youth mental health. The instruments form an integrated mental health information system because they share a common assessment language, conceptual basis, clinical emphasis, data collection approach, data elements, and care planning protocols. The key applications of these instruments include care planning, outcome measurement, quality improvement, and resource allocation. The composition of these instruments and psychometric properties are reviewed, and examples related to homeless are used to illustrate the various applications of these assessment systems.