Urban-Rural Differences in Suicide in the State of Maryland: The Role of Firearms

Disentangling the coping process in White rural men who carry guns

Affluent White rural men have the highest rates of gun ownership in the United States. However, few studies have specifically examined reasons and motivations for gun ownership and gun behaviors in this population. Therefore, this study sought to examine the relationship between stress variables, namely masculine gender role stress, adverse childhood experiences (ACEs), and income level, and subsequent pro-gun beliefs and amount of time an individual carried a gun within this population. Results indicated that only two measures of pro-gun beliefs (i.e., believing guns keep one safe, believing guns are present in one's social sphere) were correlated with percentage of time an individual carried. Additionally, ACEs were positively correlated with believing guns influence how others perceive oneself, levels of masculine gender role stress, and income. These results suggest that White rural gun owners who have increased ACEs have decreased income and tend to believe that owning guns impacts their social status with peers. However, increased ACEs do not influence belief about guns keeping one safe, believing guns are present in one's social sphere, or gun carriage. Instead, White rural gun owners without childhood adversity may be more susceptible to believing their safety depends on guns and belongingness within their social sphere. Future research should assess reasons why affluent White rural men find it important to maintain their safety in the context of gun ownership.

A PRISMA Scoping Review to Explore Interventions to Prevent Firearm-Related Injury and Suicide in Older Adults

OBJECTIVES

This scoping review aims to examine existing research into firearm safety interventions designed to prevent firearm injury and suicide in older adults.

METHODS

Select databases were searched in 5/2023. Included articles involved an/a 1. aim to develop or investigate firearm safety interventions, 2. focus on adults 50 years and older, and 3. primary analysis.

RESULTS

The search yielded 10 articles which primarily focused on firearm safety counseling with older adults with suicide risk or emerging impairment. The review found that older adults may be open to receiving firearm safety counseling but that providers feel ill-equipped to have these conversations and to reliably identify suicide risk. Two studies presented promising data on the impact and acceptability of training providers in a firearm safety intervention. The review also identified the importance of building trust between older patients and providers to have helpful discussions regarding firearms, and highlighted specific approaches that facilitate openness to participate in these exchanges.

CONCLUSIONS

Further research into adapting interventions to meet the clinical needs of older adults and treatment efficacy trials is necessary.

CLINICAL IMPLICATIONS

Training healthcare providers to conduct firearm safety interventions with older adults may be an acceptable and impactful avenue to prevent suicide.

Utah Latina/o/x suicide decedents less likely to die by firearm, even in rural areas: examining population-wide data from the Utah Office of the Medical Examiner

Introduction

Suicide death remains a significantly rarer event among Latina/o/x populations compared to non-Latina/o/x populations. However, the reasons why Latina/o/x communities experience relatively lower suicide rates are not fully understood. Critical gaps exist in the examination of Latina/o/x suicide death, especially in rural settings, where suicide death by firearm is historically more common within non-Latina/o/x populations.

Method

We tested whether the prevalence of Latina/o/x firearm suicide was meaningfully different in urban and rural environments and from non-Latino/a/x decedents when controlling for age, sex, and a social deprivation metric, the Area Deprivation Index. Suicide death data used in this analysis encompasses 2,989 suicide decedents ascertained in Utah from 2016 to 2019. This included death certificate data from the Utah Office of the Medical Examiner on all Utah suicide deaths linked to information by staff at the Utah Population Database.

Results

Compared to non-Latina/o/x suicide decedents, Latina/o/x suicide decedents had 34.7% lower adjusted odds of dying by firearm. Additionally, among the firearm suicide decedents living only in rural counties, Latina/o/x decedents had 40.5% lower adjusted odds of dying by firearm compared to non-Latina/o/x suicide decedents.

Discussion

The likelihood of firearm suicide death in Utah differed by ethnicity, even in rural populations. Our findings may suggest underlying factors contributing to lower firearm suicide rates within Latina/o/x populations, e.g., aversion to firearms or less access to firearms, especially in rural areas, though additional research on these phenomena is needed.

Firearm exposure and safety training of rural Iowa youth

PURPOSE

Our objective was to investigate rural adolescents' use of firearms and whether they had received firearm training.

METHODS

2019 Iowa FFA Leadership Conference attendees were surveyed. Descriptive and comparative analyses were performed.

RESULTS

One thousand three hundred and eighty-two FFA members aged 13-18 years participated. The vast majority (85%) had fired a rifle/shotgun; 58% reported firing them >20 times. Of those who had fired rifles/shotguns, 32% had done so before 9 years old; 79% before 13 years. Most had also fired a handgun (62%), with 30% having fired handguns >20 times. Of those who had fired handguns, 34% had done so before 11 years old. The average age for first firing rifles/shotguns was 10.1 (SD 2.9) years, and 11.9 (SD 2.8) years for handguns. Males, older teenagers, and those living on farms or in the country had significantly greater percentages that had fired a rifle/shotgun or a handgun. Greater proportions of males had used firearms >20 times and started firing them at younger ages. Over half (55%) reported having gone hunting. Of those, 24% first hunted before 9 years old; 48% before 11 years. Of those who had used a firearm, 61% had completed a firearm safety training course. For hunters, 80% had taken a course.

CONCLUSIONS

Most participants had used firearms, and many did so at very young ages. Substantial numbers had not received formal training. The authors believe that families should be counseled when it is developmentally appropriate to introduce youth to firearms, and all should take firearm safety training before using them.

Suicide Rates and Risks Across U.S. Industries: A 29-Year Population-Based Survey

OBJECTIVE

Suicide rates in the working-age U.S. population have increased by over 40% in the last two decades. Although suicide may be linked with characteristics of workplaces and their industries, few studies have reported industry-level suicide rates. No study has reported suicide rates by industry using nationally representative data. This study estimates suicide risks across industries in the U.S. working population.

METHODS

Industry-level estimates of suicide risks require substantial data; we combined 29 years of U.S. suicide data using the National Health Interview Survey (NHIS)-Mortality Linked data from 1986 through 2014, with mortality follow-up through 2015. We conducted survey-weighted Poisson regression analyses to estimate suicide mortality rates and rate ratios across all populations and stratified by gender. All analyses were adjusted first for age, and then for age, employment status, marital status, race/ethnicity, and rurality/urbanicity (demographic-adjusted). Rate ratios compared results for workers in each industry to those for all industries, accounting for the NHIS survey design.

RESULTS

A total of 1,943 suicide deaths were recorded. Age-adjusted suicide rates per 100,000 were highest in the furniture, lumber, and wood industry group (29.3), the fabricated metal industry (26.3), and mining (25.8). Demographic-adjusted rates were higher among men than women in most industries. Demographic-adjusted rate ratios were significantly elevated in the furniture, lumber, and wood industries (Rate Ratio, RR = 1.60, 95% confidence interval, CI = 1.18-2.18); chemicals and allied products (RR = 1.49, 95%CI = 1.04-2.13); and construction (RR = 1.21, 95% CI = 1.03-1.41).

CONCLUSION

Several industries had significantly high suicide rates. Suicide prevention efforts may be particularly useful for workers in those industries.

Firearm-Related Traumatic Brain Injury Homicides in the United States, 2000-2019

BACKGROUND

Traumatic brain injury (TBI) is a leading cause of homicide-related death in the United States. Penetrating TBI associated with firearms is a unique injury with an exceptionally high mortality rate that requires specialized neurocritical trauma care.

OBJECTIVE

To report incidence patterns of firearm-related and nonfirearm-related TBI homicides in the United States between 2000 and 2019 by demographic characteristics to provide foundational data for prevention and treatment strategies.

METHODS

Data were obtained from multiple cause of death records from the National Vital Statistics System using Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database for the years 2000 to 2019. Number, age-adjusted rates, and percent of firearm and nonfirearm-related TBI homicides by demographic characteristics were calculated. Temporal trends were also evaluated.

RESULTS

During the study period, there were 77 602 firearm-related TBI homicides. Firearms were involved in the majority (68%) of all TBI homicides. Overall, men, people living in metro areas, and non-Hispanic Black persons had higher rates of firearm-related TBI homicides. The rate of nonfirearm-related TBI homicides declined by 40%, whereas the rate of firearm-related TBI homicides only declined by 3% during the study period. There was a notable increase in the rate of firearm-related TBI homicides from 2012/2013 through 2019 for women (20%) and nonmetro residents (39%).

CONCLUSION

Firearm-related violence is an important public health problem and is associated with the majority of TBI homicide deaths in the United States. The findings from this study may be used to inform prevention and guide further research to improve treatment strategies directed at reducing TBI homicides involving firearms.

Challenges, Successes, and the Future of Firearm Injury Prevention

Policy Points Firearm injury is a leading cause of death in the United States, with fatality rates increasing 34.9% over the past decade (2010-2020). Firearm injury is preventable through multifaceted evidence-based approaches. Reviewing past challenges and successes in the field of firearm injury prevention can highlight the future directions needed in the field. Adequate funding, rigorous and comprehensive data availability and access, larger pools of diverse and scientifically trained researchers and practitioners, robust evidence-based programming and policy implementation, and a reduction in stigma, polarization, and politicization of the science are all needed to move the field forward.

Changes in suicide in California from 2017 to 2021: a population-based study

BACKGROUND

Suicide is a major public health problem with immediate and long-term effects on individuals, families, and communities. In 2020 and 2021, stressors wrought by the COVID-19 pandemic, stay-at-home mandates, economic turmoil, social unrest, and growing inequality likely modified risk for self-harm. The coinciding surge in firearm purchasing may have increased risk for firearm suicide. In this study, we examined changes in counts and rates of suicide in California across sociodemographic groups during the first two years of the COVID-19 pandemic relative to prior years.

METHODS

We used California-wide death data to summarize suicide and firearm suicide across race/ethnicity, age, education, gender, and urbanicity. We compared case counts and rates in 2020 and 2021 with 2017-2019 averages.

RESULTS

Suicide decreased overall in 2020 (4123 deaths; 10.5 per 100,000) and 2021 (4104; 10.4 per 100,000), compared to pre-pandemic (4484; 11.4 per 100,000). The decrease in counts was driven largely by males, white, and middle-aged Californians. Conversely, Black Californians and young people (age 10 to 19) experienced increased burden and rates of suicide. Firearm suicide also decreased following the onset of the pandemic, but relatively less than overall suicide; as a result, the proportion of suicides that involved a firearm increased (from 36.1% pre-pandemic to 37.6% in 2020 and 38.1% in 2021). Females, people aged 20 to 29, and Black Californians had the largest increase in the likelihood of using a firearm in suicide following the onset of the pandemic. The proportion of suicides that involved a firearm in 2020 and 2021 decreased in rural areas compared to prior years, while there were modest increases in urban areas.

CONCLUSIONS

The COVID-19 pandemic and co-occurring stressors coincided with heterogeneous changes in risk of suicide across the California population. Marginalized racial groups and younger people experienced increased risk for suicide, particularly involving a firearm. Public health intervention and policy action are necessary to prevent fatal self-harm injuries and reduce related inequities.

Long gun suicides in the state of Maryland following the firearm safety act of 2013

OBJECTIVES

In 2013, the state of Maryland passed the Firearms Safety Act limiting the private sales of handguns, which did not apply to long guns often used for hunting (e.g., rifles and shotguns). This decreased the accessibility of handguns relative to long guns. We assessed the frequency of long gun suicides in the years before and after the policy change during winter season, which encompasses hunting season in Maryland.

METHODS

We performed a retrospective analysis on all 4107 well-characterized adult suicides caused by firearms in Maryland from 2003 through 2019. Logistic regression was performed, stratifying by decedent sex, race, and age.

RESULTS

While handgun suicides decreased in the period after 2013's Firearm Safety Act (p < 0.008), wintertime long gun suicides increased after 2013 (p < 0.004). Caucasian race (p < 0.006), male sex (p < 0.005), and middle age (p < 0.001) were significantly associated with wintertime long gun suicides after 2013.

CONCLUSION

Our findings suggest that while the 2013 Firearms Safety Act decreased handgun suicides significantly, it did not reduce long gun suicides and there may even have been replacement with long guns during hunting season, when rifles are out and accessible. This association was most prominent among the demographics most likely to hunt (Caucasian, middle-aged, and male).

Exploring Place-Based Differences in Suicide and Suicide-Related Outcomes Among North Carolina Adolescents and Young Adults

PURPOSE

Suicide is an ongoing public health crisis among youth and adolescents, and few studies have investigated the spatial patterning in the United States among this subpopulation. Potential precursors to suicide in this vulnerable group are also on the rise, including nonfatal self-injury.

METHODS

This study uses emergency department data, death certificates, and violent death reporting system data for North Carolina from 2009 to 2018 to investigate spatial clusters of self-injury and suicide.

RESULTS

Findings show that the demographic characteristics of individuals committing fatal and nonfatal self-injury are quite different. Self-injury and completed suicides exhibited different geographical patterns. Area-level measures like micropolitan status and measures of racial and income segregation predicted the presence of high-risk suicide clusters. Suicides among Native Americans and veteran status/military personnel also were associated with higher risk suicide clusters.

DISCUSSION

Future interventions should target these specific high-risk locations for immediate reductions in adolescent and youth suicides.

Suicide Rates and Differences in Rates Between Non-Hispanic Black and Non-Hispanic White Populations in the 30 Largest US Cities, 2008-2017

OBJECTIVES

Suicide is a leading cause of death in the United States, and rates vary by race and ethnicity. An analysis of suicide across large US cities is absent from the literature. The objective of this study was to examine suicide rates among the total population, non-Hispanic Black population, and non-Hispanic White population in the United States and in the 30 largest US cities.

METHODS

We used data from the National Vital Statistics System to calculate non-Hispanic White, non-Hispanic Black, and total age-adjusted suicide rates for the 30 largest US cities and for the entire nation during 2 periods: 2008-2012 and 2013-2017. We also examined absolute and relative differences in suicide rates among non-Hispanic White populations and non-Hispanic Black populations in each city.

RESULTS

The overall age-adjusted suicide rate per 100 000 population in the United States increased significantly from 12.3 in 2008-2012 to 13.5 in 2013-2017. Total suicide rates were stable in most cities; rates increased significantly in only 1 city (Louisville), and rates decreased significantly in 2 cities (Boston and Memphis). The non-Hispanic White suicide rate was significantly higher-1.3 to 4.3 times higher-than the non-Hispanic Black suicide rate in 24 of 26 study cities during 2013-2017. From 2008-2012 to 2013-2017, non-Hispanic White suicide rates decreased significantly in 3 cities and increased significantly in 3 cities; non-Hispanic Black suicide rates increased significantly in 5 cities and decreased in none. Absolute differences in suicide rates among non-Hispanic White populations and non-Hispanic Black populations increased significantly in 1 city (Louisville) and decreased significantly in 2 cities (Memphis and Boston).

CONCLUSIONS

Our study may inform the use of evidence-based programs and practices to address population-level risk factors for suicide.

Examining the Benefits of Greenness on Reducing Suicide Mortality Rate: A Global Ecological Study

Objective

This study applied an ecological-based analysis aimed to evaluate on a global scale the association between greenness exposure and suicide mortality.

Methods

Suicide mortality data provided by the Institute for Health Metrics and Evaluation and the Normalized Difference Vegetation Index (NDVI) were employed. The generalized additive mixed model was applied to evaluate with an adjustment of covariates the association between greenness and suicide mortality. Sensitivity tests and positive-negative controls also were used to examine less overt insights. Subgroup analyses were then conducted to investigate the effects of greenness on suicide mortality among various conditions.

Results

The main finding of this study indicates a negative association between greenness exposure and suicide mortality, as greenness significantly decreases the risk of suicide mortality per interquartile unit increment of NDVI (relative risk = 0.69, 95%CI: 0.59–0.81). Further, sensitivity analyses confirmed the robustness of the findings. Subgroup analyses also showed a significant negative association between greenness and suicide mortality for various stratified factors, such as sex, various income levels, urbanization levels, etc.

Conclusions

Greenness exposure may contribute to a reduction in suicide mortality. It is recommended that policymakers and communities increase environmental greenness in order to mitigate the global health burden of suicide.

Rural-Urban Comparisons in the Rates of Self-Harm, U.S., 2018

INTRODUCTION

This study compares rural and urban differences in the rates of nonfatal self-harm in the U.S. in 2018.

METHODS

Nationwide Emergency Department Sample and Census data were analyzed to calculate the RR of emergency department visits for self-harm between rural and urban residents. The analyses were conducted in 2021.

RESULTS

Among a weighted total of 488,000 emergency department visits for self-harm in the U.S., 80.5% were urban residents, and 18.3% were rural residents. In both settings, poisoning was the most common mechanism for self-harm, followed by cutting. Firearm-related self-harm and suffocation each accounted for <2% of total self-harm cases. Overall, the age-adjusted emergency department visit rate for self-harm was 252.3 per 100,000 for rural residents, which was 1.5 (95% CI=1.4, 1.6) times greater than the rate for urban residents (170.8 per 100,000 residents). The rates of self-harm among rural residents were higher than those of urban residents for both male and female residents, for all age groups except people aged ≥65 years, and by all mechanisms.

CONCLUSIONS

Comprehensive suicide prevention strategies tailored to rural communities may mitigate the rural-urban disparity in morbidity from suicidal behavior.

Life skills training, hope, and health: An interventional study in the North West of Iran during the COVID-19 pandemic

Objectives

Suburbanization is associated with an individual's health. This study aimed to investigate the effect of life skills training on the hope and health of women referred to comprehensive health service centers in the suburbs of Khoy city.

Study design

quasi-experimental study (Pre-test/Post-test with a control group)

Methods

in this study, out of 5 comprehensive health service centers, two centers were selected as intervention and comparison groups, and from each center, 37 women were randomly selected. At first, both groups completed the Goldberg general health questionnaire and the Miller hope questionnaire, and the intervention group was taught life skills. At the end of the training, both groups were re-evaluated. Descriptive statistics such as frequency distribution and dispersion indices were used in data analysis. Mann-Whitney and Wilcoxon Signed Ranks Tests were used in inferential statistics.

Results

Group training in life skills did not significantly affect hope (P.value = 0.972) and various aspects of health (P.value = 0.421).

Conclusions

It seems that only interventions such as life skills training will not improve suburban women's hope and health. Perhaps improving social infrastructure and comprehensive living conditions in suburban areas will promote hope and health.

Suicide rates amongst individuals from ethnic minority backgrounds: A systematic review and meta-analysis

BACKGROUND

Existing evidence suggests that some individuals from ethnic minority backgrounds are at increased risk of suicide compared to their majority ethnic counterparts, whereas others are at decreased risk. We aimed to estimate the absolute and relative risk of suicide in individuals from ethnic minority backgrounds globally.

METHODS

Databases (Medline, Embase, and PsycInfo) were searched for epidemiological studies between 01/01/2000 and 3/07/2020, which provided data on absolute and relative rates of suicide amongst ethnic minority groups. Studies reporting on clinical or specific populations were excluded. Pairs of reviewers independently screened titles, abstracts, and full texts. We used random effects meta-analysis to estimate overall, sex, location, migrant status, and ancestral origin, stratified pooled estimates for absolute and rate ratios. PROSPERO registration: CRD42020197940.

FINDINGS

A total of 128 studies were included with 6,026,103 suicide deaths in individuals from an ethnic minority background across 31 countries. Using data from 42 moderate-high quality studies, we estimated a pooled suicide rate of 12·1 per 100,000 (95% CIs 8·4-17·6) in people from ethnic minority backgrounds with a broad range of estimates (1·2-139·7 per 100,000). There was weak statistical evidence from 51 moderate-high quality studies that individuals from ethnic minority groups were more likely to die by suicide (RR 1·3 95% CIs 0·9-1·7) with again a broad range amongst studies (RR 0·2-18·5). In our sub-group analysis we only found evidence of elevated risk for indigenous populations (RR: 2·8 95% CIs 1·9-4·0; pooled rate: 23·2 per 100,000 95% CIs 14·7-36·6). There was very substantial heterogeneity (I²  > 98%) between studies for all pooled estimates.

INTERPRETATION

The homogeneous grouping of individuals from ethnic minority backgrounds is inappropriate. To support suicide prevention in marginalised groups, further exploration of important contextual differences in risk is required. It is possible that some ethnic minority groups (for example those from indigenous backgrounds) have higher rates of suicide than majority populations.

FUNDING

No specific funding was provided to conduct this research. DK is funded by Wellcome Trust and Elizabeth Blackwell Institute Bristol. Matthew Spittal is a recipient of an Australian Research Council Future Fellowship (project number FT180100075) funded by the Australian Government. Rebecca Musgrove is funded by the NIHR Greater Manchester Patient Safety Translational Research Centre (PSTRC-2016-003).

Consensus-Driven Priorities for Firearm Injury Education Among Medical Professionals

PURPOSE

Firearm injury is a leading cause of morbidity and mortality in the United States. However, many medical professionals currently receive minimal or no education on firearm injury or its prevention. The authors sought to convene a diverse group of national experts in firearm injury epidemiology, injury prevention, and medical education to develop consensus on priorities to inform the creation of learning objectives and curricula for firearm injury education for medical professionals.

METHOD

In 2019, the authors convened an advisory group that was geographically, demographically, and professionally diverse, composed of 33 clinicians, researchers, and educators from across the United States. They used the nominal group technique to achieve consensus on priorities for health professions education on firearm injury. The process involved an initial idea-generating phase, followed by a round-robin sharing of ideas and further idea generation, facilitated discussion and clarification, and the ranking of ideas to generate a prioritized list.

RESULTS

This report provides the first national consensus guidelines on firearm injury education for medical professionals. These priorities include a set of crosscutting, basic, and advanced learning objectives applicable to all contexts of firearm injury and all medical disciplines, specialties, and levels of training. They focus on 7 contextual categories that had previously been identified in the literature: 1 category of general priorities applicable to all contexts and 6 categories of specific contexts, including intimate partner violence, mass violence, officer-involved shootings, peer (nonpartner) violence, suicide, and unintentional injury.

CONCLUSIONS

Robust, data- and consensus-driven priorities for health professions education on firearm injury create a pathway to clinician competence and self-efficacy. With an improved foundation for curriculum development and educational program-building, clinicians will be better informed to engage in a host of firearm injury prevention initiatives both at the bedside and in their communities.

Polysubstance Overdose Deaths in the Fentanyl Era: A Latent Class Analysis

OBJECTIVES

To elucidate the main latent classes of substances detected among overdose decedents, and latent class associations with age, sex, race, and jurisdiction of death in Maryland.

METHODS

We used toxicology data from the Office of the Chief Medical Examiner of Maryland for all decedents. We analyzed all cases of drug overdose deaths that occurred from 2016 to 2018 (N = 6566) using latent class analysis and regression.

RESULTS

Drug overdose deaths were concentrated in 2 of 24 counties in Maryland (Baltimore City and County). Fentanyl was involved in 71% of all drug overdose deaths, and the majority (76%) of these deaths included multiple substances. Three latent classes emerged: (1) fentanyl/heroin/cocaine (64%); (2) fentanyl/alcohol (18%); and (3) prescription drugs including opioids, benzodiazepines and antidepressants (18.0%). The fentanyl/heroin/cocaine class members were significantly younger (<30 years), female and White compared to the fentanyl/alcohol class, but more male and non-White than the prescription drugs class (all P < 0.05). Deaths in Baltimore City/County were more likely than in other locations to involve fentanyl/alcohol (P < 0.05).

CONCLUSIONS

The majority of fentanyl-involved overdose deaths in Maryland involved multiple substances, and several demographic and geographic differences in these patterns emerged. Geographically-targeted interventions that are tailored to reduce the harms associated with polysubstance use (including cocaine, alcohol, and prescription drugs) for different demographic groups are warranted.

Incidence and Risk of Suicide Among Patients With Head and Neck Cancer in Rural, Urban, and Metropolitan Areas

Importance

Patients with head and neck cancer (HNC) are known to be at increased risk of suicide compared with the general population, but there has been insufficient research on whether this risk differs based on patients' rural, urban, or metropolitan residence status.

Objective

To evaluate whether the risk of suicide among patients with HNC differs by rural vs urban or metropolitan residence status.

Design, Setting, and Participants

This cross-sectional study uses data from the Surveillance, Epidemiology, and End Results database on patients aged 18 to 74 years who received a diagnosis of HNC from January 1, 2000, to December 31, 2016. Statistical analysis was conducted from November 27, 2020, to June 3, 2021.

Exposures

Residence status, assessed using 2013 Rural Urban Continuum Codes.

Main Outcomes and Measures

Death due to suicide was assessed by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes (U03, X60-X84, and Y87.0) and the cause of death recode (50220). Standardized mortality ratios (SMRs) of suicide, assessing the suicide risk among patients with HNC compared with the general population, were calculated. Suicide risk by residence status was compared using Fine-Gray proportional hazards regression models.

Results

Data from 134 510 patients with HNC (101 142 men [75.2%]; mean [SE] age, 57.7 [10.3] years) were analyzed, and 405 suicides were identified. Metropolitan residents composed 86.6% of the sample, urban residents composed 11.7%, and rural residents composed 1.7%. The mortality rate of suicide was 59.2 per 100 000 person-years in metropolitan counties, 64.0 per 100 000 person-years in urban counties, and 126.7 per 100 000 person-years in rural counties. Compared with the general population, the risk of suicide was markedly higher among patients with HNC in metropolitan (SMR, 2.78; 95% CI, 2.49-3.09), urban (SMR, 2.84; 95% CI, 2.13-3.71), and rural (SMR, 5.47; 95% CI, 3.06-9.02) areas. In Fine-Gray competing-risk analyses that adjusted for other covariates, there was no meaningful difference in suicide risk among urban vs metropolitan residents. However, compared with rural residents, residents of urban (subdistribution hazard ratio, 0.52; 95% CI, 0.29-0.94) and metropolitan counties (subdistribution hazard ratio, 0.55; 95% CI, 0.32-0.94) had greatly lower risk of suicide.

Conclusions and Relevance

The findings of this cross-sectional study suggest that suicide risk is elevated in general among patients with HNC but is significantly higher for patients residing in rural areas. Effective suicide prevention strategies in the population of patients with HNC need to account for rural health owing to the high risk of suicide among residents with HNC in rural areas.

Prior health care utilization among adolescents treated for a suicide attempt at a rural ED

PURPOSE

To characterize prior contact with a rural academic health system among young people treated for a suicide attempt in the system's emergency departments (EDs).

METHODS

We retrospectively examined electronic medical records from a health system serving 29 medically underserved rural counties in the Southeastern United States. Patients ages 10-25 years were included in the study if they were admitted to the ED for a suicide attempt in 2015-2018. Patients were stratified according to whether they had any encounter in the same health system in the 12 months prior to the attempt.

FINDINGS

Of 236 patients meeting inclusion criteria, only 10% had contact with the health system in the 12 months prior to ED treatment for a suicide attempt. Patients who lived farther than 25 km from the flagship hospital were less likely to have had prior contact (odds ratio [OR]: 0.10, 95% confidence interval [CI]: 0.02-0.34). Young adults ages 19-25 years were also less likely to have prior contact than adolescents (OR: 0.27, 95% CI: 0.08-0.76).

CONCLUSIONS

Few adolescents and young adults in this rural region received prior health care from the same health system where they were treated for a suicide attempt. Hospitals operating in rural areas need to partner with community health care providers to ensure adequate reach of screening and treatment programs to prevent youth suicide and reduce care fragmentation.

Development of an online map of safe gun storage sites in Maryland for suicide prevention

Reducing access to lethal means of self-harm is a cornerstone of suicide prevention, and temporary, voluntary gun storage outside the home is one recommended approach. With the goal of facilitating access to gun storage outside the home in Maryland, we developed an online map of gun shops and law enforcement agencies willing to offer temporary, voluntary gun storage on a case-by-case basis. This project was modelled off of prior work by the Colorado Firearm Safety Coalition. As of July 2020, 32 gun shops and 3 law enforcement agencies agreed to be listed on our map. Others were hesitant to participate due to perceived legal and logistical barriers to temporary firearm storage. We demonstrate the feasibility of creating an online map that lists organisations offering temporary gun storage in Maryland. This brief report details our process, barriers encountered, and future considerations to improve access to offsite gun storage options.

Psychiatric diagnoses are associated with means selection in united states suicide deaths

PURPOSE

The purpose of this study was to examine whether the choice of means by persons who die by suicide is associated with a prior psychiatric diagnosis.

METHODS

In this cross-sectional study, we analyzed suicide surveillance data from 18 states reporting to the National Violent Death Reporting System (NVDRS) between 2003 and 2014. NVDRS compiled data from multiple sources (e.g., coroner's reports, police reports, death certificates) on every violent death within reporting jurisdictions, including information on indicated psychiatric disorders and suicide means. We assessed whether the selected suicide means were associated with diagnoses using multinomial logistic regression.

RESULTS

Adjusted models suggested that, compared to decedents using firearms, those using poisoning were more likely to have each psychiatric disorder examined, including bipolar disorder (aOR: 2.17 [95% CI 2.03-2.32]), schizophrenia (aOR: 1.81 [1.61-2.04]), depression (aOR: 1.64 [1.58-1.70]), anxiety disorder (aOR: 1.46 [1.35-1.57]), and PTSD (aOR: 1.41 [1.22-1.64]). A far greater proportion of individuals who died from less common means (other than firearms, suffocation, or poisoning) had schizophrenia (aOR: 4.52 [4.00-5.11]).

CONCLUSIONS

Many existing and proposed means restriction interventions have focused on firearms. Additional focus on access to potential agents of poisoning (e.g., the type and quantity of medication administered to patients) among individuals with psychiatric diagnoses may be warranted.

Rural-Urban Differences in Suicide Mortality: An Observational Study in Newfoundland and Labrador, Canada: Différences de la Mortalité Par Suicide en Milieu Rural-Urbain: Une Étude Observationnelle à Terre-Neuve et Labrador, Canada

BACKGROUND

Suicide rates are higher in rural compared to urban areas. Although this pattern appears to be driven by higher rates among men, there is limited evidence about the characteristics of rural people who die by suicide in Canada. The objective of this study was to examine the demographics, manner of death, and social and clinical antecedents of people who died by suicide in rural areas compared to urban areas.

METHODS

We conducted an observational study of all suicide deaths that occurred among Newfoundland and Labrador residents between 1997 and 2016 using a linked data set derived from a comprehensive review of provincial medical examiner records. We used t tests and χ² to assess associations between rural/urban status and variables related to demographics, circumstances, and manner of death, as well as social and medical history. Logistic regression was utilized to assess the independent contribution of any variable found to be significant in univariate analysis.

RESULTS

Rural people who died by suicide accounted for 54.8% of all deaths over a 20-year period. Overall, 81.6% of people who died were male. Compared to urban, rural people who died by suicide were younger, more likely to use firearms or hanging, and had a higher mean blood alcohol content at the time of death (27.69 vs. 22.95 mmol/L). Rural people were also less likely to have had a known history of a prior suicide attempt, psychiatric disorder, alcohol or substance abuse, or chronic pain.

DISCUSSION

The demographic and clinical differences between rural and urban people who died by suicide underscore the need for suicide prevention approaches that account for place-based differences. A key challenge for suicide prevention in rural communities is to ensure that interventions are developed and implemented in a manner that fits local contexts.

Rural youth's exposure to firearm violence and their attitudes regarding firearm safety measures

BACKGROUND

In the wake of an epidemic in firearm-related deaths and injuries, youth have become leading voices of concern. This study's objective was to investigate rural youth's personal experiences with firearm-related violence, and their attitudes towards firearms and gun violence prevention strategies.

METHODS

Attendees of the 2019 Iowa FFA Leadership Conference were surveyed about personal experiences with firearm-associated deaths and injuries, and their attitudes regarding firearm-related issues. Descriptive (frequencies), bivariate (chi square, Fisher's exact test) and multivariable logistic regression analyses were performed utilizing Stata 15.1 (StataCorp, College Station, Texas).

RESULTS

Responses from 1382 FFA members 13-18 years of age were analyzed. About 5% had personally seen someone threatened with a firearm. Over one-third (36%) stated they knew someone who had been killed or injured by gunfire. Of these, over two-thirds knew of someone who had died or was injured unintentionally and 30% knew of someone killed or injured intentionally (e.g. suicide). Nearly all agreed or strongly agreed that the right to use firearms for hunting and shooting sports should be legal (94%), that a firearm safety course should be required to get a hunting license (89%), and that there should be a required background check before purchasing a firearm (89%). Over three-fifths (61%) agreed or strongly agreed that there should be laws requiring safe storage of firearms in homes. Although still high, lesser support for firearm safety policies was seen among males, older youth, participants living on farms or in the country, and youth who hunted, had firearms in their homes, and/or were in homes with unsafe firearm storage.

CONCLUSIONS

The majority of youth in this study supported firearm safety measures including required training, background checks, and safe firearm storage in homes. These findings are consistent with the national youth-led call for firearm safety. Additionally, over one-third of respondents personally knew someone who was killed or injured by a firearm and 5% had seen someone or been personally threatened with firearm violence. Our study did not investigate the effects of firearm violence on participants' mental health and wellbeing, but future studies addressing this question seem highly justified.

Suicide and the opioid overdose crisis among American Indian and Alaska Natives: a storm on two fronts demanding swift action

The opioid crisis in the United States has received national attention and critical resources in the past decade. However, what has been overlooked is the effect the opioid crisis may be having on a three-decade suicide crisis among American Indian and Alaska Native (AIAN) communities that already have too few resources to address behavioral and mental health issues. This paper describes recent epidemiological trends associated with both opioid overdose and suicide at a national level for AIANs and the rest of the United States. We used data reported by the Centers for Disease Control and Prevention to report historical trends of opioid overdose and suicide for AIAN and non-AIAN populations. We found alarming and potentially correlated trends of opioid use and suicidality among AIAN populations. We highlight both current and future research that will be essential to understanding and addressing the unique intersection between opioid and suicide risk and protective factors to inform dual prevention and intervention efforts among AIAN populations with potential relevance to public health response among other at-risk populations.

Suicide Distribution and Trends Among Male Older Adults in the U.S., 1999-2018

INTRODUCTION

This study examines the distribution and trends in suicide death rates among male adults aged ≥65 years in the U.S. from 1999 to 2018.

METHODS

Suicide mortality data were derived from Multiple Cause of Death from the Center for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research database. Suicides were identified from the underlying causes of death. Joinpoint regression examined the distribution and shift in suicide age-adjusted death rates overall and by age groups, race/ethnicity, method of suicide, and urbanicity. Analyses were conducted in 2020.

RESULTS

Between 1999 and 2018, a total of 106,861 male adults aged ≥65 years died of suicide (age-adjusted rate=31.4 per 100,000 population, 95% CI=31.2, 31.6). Suicide rates showed a V-shaped trend. They were declining annually by 1.8% (95% CI= -2.4, -1.2); however, starting in 2007, there was a shift upward, increasing significantly by 1.7% per year for the next decade (95% CI=1.0, 1.6). Suicide rates were highest among those aged ≥85 years (48.8 per 100,000 population with an upward shift in 2008), Whites (35.3 per 100,000 population with an upward shift in trend in 2007), and the most rural communities (39.0 per 100,000 population). Most suicides were due to firearms (78.3% at a rate of 24.7 per 100,000 population), especially in rural areas, and shifted upward after 2007.

CONCLUSIONS

Increases in suicide rates among male older adults in the U.S., particularly after the 2007-2008 economic recession, are concerning. Tailored suicide prevention intervention strategies are needed to address suicide-related risk factors.

Firearm-related injuries and deaths in Ontario, Canada, 2002-2016: a population-based study

BACKGROUND

Firearm-related injury is an important and preventable cause of death and disability. We describe the burden, baseline characteristics and regional rates of firearm-related injury and death in Ontario.

METHODS

We conducted a population-based cross-sectional study using linked data from health administrative data sets held at ICES. We identified residents of Ontario of all ages who were injured or died as a result of a firearm discharge between Apr. 1, 2002, and Dec. 31, 2016. We included injuries classified as assault, unintentional, self-harm or undetermined intent secondary to handguns, rifles, shotguns and larger firearms. The primary outcome was the incidence of nonfatal and fatal injuries resulting in an emergency department visit, hospital admission or death. We also describe regional and temporal rates.

RESULTS

We identified 6483 firearm-related injuries (annualized injury rate 3.54 per 100 000 population), of which 2723 (42.3%) were fatal. Assault accounted for 40.2% (1494/3715) of nonfatal injuries and 25.5% (694/2723) of deaths. Young men, predominantly in urban neighbourhoods, within the lowest income quintile were overrepresented in this group. Injuries secondary to self-harm accounted for 68.0% (1366/2009) of injuries and occurred predominantly in older men living in rural Ontario across all income quintiles. The case fatality rate of injuries secondary to self-harm was 91.7%. Self-harm accounted for 1842 deaths (67.6%).

INTERPRETATION

We found that young urban men were most likely to be injured in firearm-related assaults and that more than two-thirds of self-harm-related injuries occurred in older rural-dwelling men, most of whom died from their injuries. This highlights a need for suicide-prevention strategies in rural areas targeted at men aged 45 or older.

Annual Research Review: Youth firearm violence disparities in the United States and implications for prevention

OBJECTIVE

Research has identified the United States (U.S.) as a global outlier in its firearm ownership rates, with a correspondingly higher risk of youth firearm violence compared to other countries. The relative extent of disparities in youth firearm violence within the U.S. has been less clear. Little is known about factors in the social ecology driving these disparities and whether current firearm violence prevention approaches sufficiently address them.

METHOD

Applying a health disparities framework, we synthesized epidemiological, sociological, and prevention science literatures, emphasizing structural inequalities in youth sociocultural positionality in life course developmental context. We also highlighted findings from national injury data and other studies regarding the magnitude and impacts of youth firearm violence disparities.

RESULTS

The burden of firearm violence varied markedly at intersections of gender, race, place, developmental stage, and homicidal or suicidal intent. Firearm homicide among Black boys and young men (ages 15-24) was at outlier levels - many times greater than the rates of any other demographic group, developmental stage, or violence intent, particularly in urban settings. Recent research has operationalized structural racism and implicated historically racialized spaces as a root cause of this disparity. In contrast, elevated firearm suicide rates were found among Native and White boys and young men in rural settings; firearm-related cultural attitudes and gender socialization were points of consideration to explain these disparities. We highlighted research-based youth firearm violence preventive interventions, and emphasized gaps in efforts focused on structural and sociocultural factors.

CONCLUSIONS

More explicit attention to reducing firearm homicide among Black boys and young men and firearm suicide among Native and rural White boys and young men is urgently needed and has potential to substantially lower overall rates of firearm violence in the U.S.

A closer look at patterns and characteristics of suicide in Lebanon: A first nationwide report of cases from 2008 to 2018

BACKGROUND

Suicide is a leading preventable cause of mortality worldwide. Suicide rates in Lebanon are unknown, as reported numbers are extrapolated and modeled over neighboring countries with poor quality of vital registration data.

METHODS

Numbers of death by suicide were obtained from the Internal Security Forces records from January 2008 through December 2018. Records from 2011 through 2018 specified the gender of the individual, the means of the suicide, the date and place of suicide. As of March 2014, nationality of the individual was recorded.

RESULTS

The total recorded number of completed suicides over 11 years is 1366 with an annual rate ranging between 1.87 and 2.4 per 100,000 capita. The male to female ratio was 2:1. Death by firearms (41.4 %) was the most common means used, followed by hanging (26.5 %), jumping from a height (13.6 %), and poisoning (13.5 %). Males were more likely to use firearms while females were more likely to use hanging or jumping from a height (p < 0.001), the latter being a common finding in non-Lebanese nationals (Ethiopian). Suicides were most common in Mount Lebanon and least common in Nabatieh governates, while their distribution across seasons was similar.

CONCLUSION

In Lebanon, like most of the Middle Eastern countries, suicide is a social and religious taboo. Our study shows a sizable prevalence of suicide rates, particularly after national efforts to improve awareness and reporting. Suicide means and vulnerable populations should be at the heart of targeted prevention strategies.

Influence of contextual factors on death by suicide in rural and urban settings

PURPOSE

To examine the association between contextual factors, represented by geographic and community health variables, and suicide among rural and urban Department of Veterans Affairs health care users (VA users).

METHODS

We performed a retrospective cohort study of 12,700,847 VA users between 2003 and 2017. We assigned contextual factors based on individuals' home address at the ZIP Code (area deprivation), county (sunlight exposure, altitude, and community health), and state level (firearm ownership), using publicly available data sources. We grouped contextual factors by quintiles or prespecified thresholds, depending on the nature of each variable. We obtained mortality data from the National Death Index. We measured the effect of living in a place with the highest versus lowest level of each contextual factor on odds of suicide using logistic regression, adjusting for individual compositional factors abstracted from VA electronic medical records data. We used random forest modeling to build prediction models for suicide based on contextual factors among rural and urban veterans.

FINDINGS

Almost all contextual factors we examined were significantly associated with suicide among rural and urban VA users, even after adjusting for individual compositional factors. However, no contextual variables were strong protective or risk factors (0.5<OR>2.0), and prediction models leveraging these contextual factors had poor accuracy among both rural (0.51, 95% CI: 0.48-0.54) and urban (0.53, 95% CI: 0.51-0.55) VA users.

CONCLUSIONS

A wide variety of contextual factors is significantly associated with suicide among rural and urban VA users. However, the factors we measured contributed very little to individual-level suicide risk.

A Systematic Review of Factors Impacting Suicide Risk Among Rural Adults in the United States

PURPOSE

Suicide rates continue to be significantly higher in rural compared to urban communities in the United States, with the suicide rate disparity continuing to grow since 1999. This systematic review synthesizes rural-specific factors related to increased suicide risk.

METHODS

OVID Medline, EMBASE, OVID PsycINFO, Web of Science, SocINDEX, Cochrane Library, and Google Scholar were searched for articles published after 2003 investigating rural adult suicide in the United States. Selection criteria were: (1) study participants > 18 years old; (2) included rural participants or communities; (3) included suicidal self-directed violence outcomes; (4) within the United States; (5) published after 2003; (6) presented peer-reviewed original data; (7) identified rural-specific risk or protective factors for suicide or barriers to treatment.

FINDINGS

Of the 1,058 records screened, 34 studies were included. The strength of evidence was relatively stronger for individual level factors including lethal means, alcohol and substance use.

CONCLUSIONS

Access to firearms is strongly related to elevated rural US suicide rates, with substance use, economic stress, and behavioral health care utilization as additional individual level factors that may contribute to the disparity. At the community level, economic distress and access to care were commonly identified factors. Future research should better quantify how risk factors contribute to rural suicide and examine interdependence across social-ecological levels. Suicide prevention efforts for the rural United States must address access to lethal means, in particular the use of firearms, and navigate limited access to quality behavioral health care.

Does population density moderate suicide risk? An Italian population study over the last 30 years

Background.

The relationship between population density and suicide risk remains unclear. While urbanization is associated with greater risk for psychopathology, higher suicide rates have been reported in rural areas. We examined population density and suicide in the Italian population in the last 30 years.

Methods.

The Italian National Institute of Statistics databases of the Italian population aged 15 years and older (52.4 million in 2016) were used to compute age-adjusted annual total mortality and suicide rates for the years 1985–2016. According to the European Union statistical office (EUROSTAT) criteria, municipalities were classified into densely populated areas, intermediate density areas, or thinly populated areas. Rate ratios (RRs) were computed by sex, age, and geographical area, using densely populated areas as reference.

Results.

Total mortality was not associated with population density. In males, suicide rate increased with decreasing population density (RR = 1.17, 95% confidence interval [CI]:1.08–1.28, in intermediate population areas, and RR = 1.32, 95% CI: 1.20–1.45, in thinly populated areas, in 2016). This inverse relationship was found across age, geographical areas, and consecutively over 22 years (1994–2016). In females, no significant difference was detected (RR = 0.96, 95% CI: 0.82–1.13 in intermediate density areas and RR = 1.02, 95% CI: 0.85–1.22 in thinly populated areas). Hanging was the most common suicide method among males, more frequent in thinly (58.8%) than intermediate (53.2%) or densely (41.4%) populated areas.

Conclusions.

A consistent and temporally stable inverse relationship between population density and suicide was found in the male, but not female, population. Men may be more vulnerable to adverse social and economic factors associated with lower population density.

Clinical Perspective on Opioids in the Context of Suicide Risk

Psychiatrists are on the front lines of two simultaneous public health crises: the increasing rates of suicide and opioid-related deaths. In this review, the authors discuss ways in which these two classes of preventable deaths may be linked, with an emphasis on identifying and preventing both outcomes through increased understanding of their shared risk factors. As clinicians, it is crucial to maintain awareness of the ways in which opioid use may contribute to depression and suicidality, as well as how mood disorders may complicate opioid use. In light of this interplay, interventions which target risk factors for both suicide and overdose are key. Interventions include early treatment of substance dependence and depression, as well as harm reduction measures, such as provision of naloxone, medication-assisted treatments for dependency, and multidisciplinary approaches to chronic pain that do not rely solely on escalating opioid doses. It is also important to address social determinants of health, which may increase risk for both accidental and intentional overdose. The roads to overdose and suicide overlap considerably and cannot be considered separately.

Prevalence of long gun use in Maryland firearm suicides

Background

Firearms account for the majority of US suicides, largely due to lethality and accessibility. Under Federal and Maryland law, long guns are less regulated than handguns which is a concern for increased suicide risk. This study uses Maryland data to ascertain the impact of long guns on suicides in the state. We hypothesize that the prevalence of long gun use among firearm suicides will be increased in rural and young populations.

Methods

This is a cross sectional study using police and medical examiner narratives to identify firearm type involved in all 3931 Maryland gun suicides from 2003 to 2018. Proportions of firearm suicides utilizing long guns were calculated. Urban-rural differences were determined using the National Center for Health Statistics’ classification system. Logistic regression was used to calculate odds ratios of long gun to handgun suicides across the urban-rural spectrum, controlling for decedent demographics.

Results

From 2003 to 2018, 28.4% of Maryland gun suicides used long guns. The proportion of long guns used was highest in the most rural counties, where 51.6% of firearm suicides were by long gun, compared to 16.8% in the most urban counties. Long guns were disproportionately used by the young. For decedents 18 or younger, 44.6% used long guns, compared to 20.2% in those 65 or older. Compared to the most urban counties, firearm suicide decedents in the most rural counties were 3.74x more likely to use long guns (OR = 3.74; 95% CI 2.19, 6.40; p < .001) after adjusting for demographics, intoxication, and hunting season.

Conclusions

Long guns are used in a large proportion of Maryland firearm suicides, particularly in rural areas and disproportionately in youth suicides. Long guns must be considered as part of access to lethal means or policy strategies in efforts to reduce the burden of firearm suicide.

Suicide Case-Fatality Rates in the United States, 2007 to 2014: A Nationwide Population-Based Study

BACKGROUND

The suicide case-fatality rate (CFR)-the proportion of suicidal acts that are fatal-depends on the distribution of methods used in suicidal acts and the probability of death given a particular method (method-specific CFR).

OBJECTIVE

To estimate overall and method-specific suicide CFRs and the distribution of methods used in suicidal acts by demographic characteristics.

DESIGN

Cross-sectional study.

SETTING

United States, 2007 to 2014.

PARTICIPANTS

Suicide deaths (n = 309 377 records from the National Vital Statistics System) and nonfatal suicide attempts requiring treatment in an emergency department (ED) (n = 1 791 638 records from the Nationwide Emergency Department Sample) or hospitalization (n = 1 556 871 records from the National [Nationwide] Inpatient Sample) among persons aged 5 years or older.

MEASUREMENTS

Rates of suicide deaths and nonfatal suicide attempts, overall and method-specific CFRs, and distribution of methods used, by sex, age group, region, and urbanization.

RESULTS

Overall, 8.5% of suicidal acts were fatal (14.7% for males vs. 3.3% for females; 3.4% for persons aged 15 to 24 years vs. 35.4% for those aged ≥65 years). Drug poisoning accounted for 59.4% of acts but only 13.5% of deaths; firearms and hanging accounted for only 8.8% of acts but 75.3% of deaths. Firearms were the most lethal method (89.6% of suicidal acts with a firearm resulted in death), followed by drowning (56.4%) and hanging (52.7%). Method-specific CFRs were higher for males and older persons. The distribution of methods varied across demographic groups.

LIMITATIONS

Results are based on suicidal acts resulting in an ED visit, a hospitalization, or death. Consequently, the reported CFRs are larger than they would have been had the data included nonfatal attempts that did not result in an ED visit.

CONCLUSION

Variation in overall suicide CFR between sexes and across age groups, regions, and urbanization is largely explained by the distribution of methods used in suicidal acts.

PRIMARY FUNDING SOURCE

Joyce Foundation.

Risk factors for suicide attempts among rural youth with a history of suicidal ideation

Youths in rural areas have approximately double the risk for suicide than do urban youth. This study analyzed data from 580 youth aged 10 to 17-years-old who endorsed lifetime suicidal ideation on intake at three large rural behavioral health centers. Results indicated that a five-factor model including older age, number of inpatient hospitalizations, gender (female), impaired legal functioning, and higher impulsivity accounted for the most variance in differentiation between ideators and attempters. These results advance our assessment of rural youth who may be at increased risk for a suicide attempt.

Rural mental health service utilization in a Texas telepsychology clinic

OBJECTIVE

To determine if service utilization behaviors varied with the remoteness of clients served by a telepsychology clinic in a predominantly rural health professional shortage area (HPSA) in Texas.

METHODS

Archival data from 290 low-income clients were analyzed to test associations between service utilization behaviors and clients' distance from the nearby access points where they traveled to receive counseling services from remotely located counselors.

RESULTS

Distance to access points did not predict differences in service utilization behaviors. However, clients in rural counties traveled farther to receive services than clients in metropolitan areas. Some utilization behaviors varied by demographic variables and depressive symptom severity.

CONCLUSIONS

A "hub and spoke" model of telehealth service delivery is an acceptable model for improving access to mental health care services in rural and underserved communities, even for clients who live relatively far from access points. Telehealth providers should consider geographic, socioeconomic, transportation, and health-related barriers to care experienced by clients when implementing services and policies.

Rural-Urban Disparities in Pregnancy Intentions, Births, and Abortions Among US Adolescent and Young Women, 1995-2017

Objectives. To examine rural-suburban-urban disparities in intendedness and resolution of first pregnancies among adolescent and young women (aged 15-19 and 20-24 years) across racial/ethnic backgrounds in the United States.Methods. We used the National Survey of Family Growth and pooled pregnancy files from 2002 through the 2015-2017 surveys. We report baseline rural-suburban-urban disparities in first pregnancy intention and outcomes. We used multinomial logistic regression to estimate these disparities, accounting for sociodemographic background, religious upbringing, and other factors.Results. The first adolescent pregnancies of rural women were more likely to be unintended and end in live birth relative to their urban counterparts. Disparities were most striking among Black adolescents, with about 60% of first adolescent pregnancies among rural Black women being unintended and ending in live birth (urban: 51%). Newly collected state health department data on rural and urban adolescent births and abortions corroborate the findings from the National Survey of Family Growth.Conclusions. Rural-urban differences in the share of first adolescent pregnancies ending in live births are not accounted for by pregnancy intention or confounding individual-level characteristics. Future research should explore the role of structural barriers, including access to family planning and abortion services.

Reweighing the Ethical Tradeoffs in the Involuntary Hospitalization of Suicidal Patients

Suicide is the 10th leading cause of death in the United States and the second cause of death among those ages 15-24 years. The current standard of care for suicidality management often involves an involuntary hospitalization deemed necessary by the attending psychiatrist. The purpose of this article is to reexamine the ethical tradeoffs inherent in the current practice of involuntary psychiatric hospitalization for suicidal patients, calling attention to the often-neglected harms inherent in this practice and proposing a path for future research. With accumulating evidence of the harms inherent in civil commitment, we propose that the relative value of this intervention needs to be reevaluated and more efficacious alternatives researched. Three arguments are presented: (1) that inadequate attention has been given to the harms resulting from the use of coercion and the loss of autonomy, (2) that inadequate evidence exists that involuntary hospitalization is an effective method to reduce deaths by suicide, and (3) that some suicidal patients may benefit more from therapeutic interventions that maximize and support autonomy and personal responsibility. Considering this evidence, we argue for a policy that limits the coercive hospitalization of suicidal individuals to those who lack decision-making capacity.

Contextual Factors Associated With County-Level Suicide Rates in the United States, 1999 to 2016

IMPORTANCE

Understanding geographic and community-level factors associated with suicide can inform targeted suicide prevention efforts.

OBJECTIVES

To estimate suicide rates and trajectories, assess associated county-level contextual factors, and explore variation across the rural-urban continuum.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included all individuals aged 25 to 64 years who died by suicide from January 1, 1999, to December 31, 2016, in the United States. Spatial analysis was used to map excess risk of suicide, and longitudinal random-effects models using negative binomial regression tested associations of contextual variables with suicide rates as well as interactions among county-level contextual variables. Data analyses were conducted between January 2019 and July 2019.

EXPOSURE

County of residence.

MAIN OUTCOMES AND MEASURES

Three-year county suicide rates during an 18-year period stratified by rural-urban location.

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 county-level 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.

Suicide in Parkinson's disease

Persons with Parkinson's disease (PwP) have many known risk factors for suicide and suicidal ideation (SI). Despite this, there is limited understanding of suicidality in this population. We conducted a systematic review to synthesise the available literature on suicidality in PwP and highlight areas for potential intervention and further research. We identified 116 articles discussing SI, suicidal behaviours, suicide attempts and/or fatal suicide in PwP. These articles describe prevalence, suicide methods, risk factors for suicide and SI and treatment of suicidality. In this review, we summarise the current literature and provide suggestions for how clinicians can identify and treat PwP who are at risk for suicide, for example, through aggressive treatment of depression and improved screening for access to lethal means.

What Are We Aiming For? Comparing Suicide by Firearm in Toronto With the Five Largest Metropolitan Areas in the United States

Background: US suicide rates correlate with firearm availability. Little is known about variability in rates across countries. Aims: To observe the relationship between firearm/overall suicide rates in Toronto, Canada, and the five most populous US metropolitan areas. Method: Centers for Disease Control suicide rates by age and sex for New York, Los Angeles, Chicago, Dallas-Fort Worth, and Houston metropolitan areas were compared with equivalent data for Toronto (1999-2015). Results: Suicide rates by firearm, per 100,000 population, ranged from 0.45 in Toronto to 6.03 in Houston while rates by other methods ranged from 4.34 in Dallas-Fort Worth to 7.11 in Toronto. Overall rates of suicide ranged from 6.14 in New York to 10.45 in Houston. The two cities with the highest firearm suicide rates, Dallas-Fort Worth and Houston, also had much higher overall rates. Firearm suicides were most common in men over the age of 65 in all cities. Limitations: This study could not account for cultural differences between cities/countries. Conclusion: Much higher overall rates of suicide observed for Dallas-Fort Worth and Houston appear to be associated with high rates of suicide by firearm. Advocacy for means safety should target cities with high rates of firearm suicide and, in particular, elderly men.

Family Firearm Ownership and Firearm-Related Mortality Among Young Children: 1976-2016

: media-1vid110.1542/5972298231001PEDS-VA_2018-1171Video Abstract BACKGROUND: Firearm-related fatalities are a top 3 cause of death among children in the United States. Despite historical declines in firearm ownership, the firearm-related mortality rate among young children has risen over the past decade. In this study, we examined changes in firearm ownership among families with young children from 1976 to 2016, exploring how such changes relate to recent increases in firearm-related mortality among 1- to 5-year-olds.

METHODS

Individual-level data from the National Vital Statistics System were merged with household-level data from the General Social Survey to create national-level estimates of firearm-related child mortality and family firearm ownership from 1976 to 2016 (n = 41 years). Vector autoregression models were used to examine the association between firearm ownership and child mortality.

RESULTS

The proportion of non-Hispanic white families with young children who owned firearms declined from 50% in 1976 to 45% in 2016 and from 38% to 6% among non-Hispanic African American families. The proportion of white families with young children who owned handguns, however, increased from 25% to 32%; 72% of firearm-owning families with young children now own a handgun. Increases in handgun ownership partially explained the recent rise in firearm-related white child mortality (B = 0.426), net of economic conditions, and sociodemographic characteristics of firearm-owning families.

CONCLUSIONS

Changes in the types of firearms in the homes of US families may partially explain recently rising firearm-related mortality among young white children. These findings hold relevance for pediatricians and policy makers aiming to reduce firearm-related mortality and promote firearm safety in children's homes.