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    2 Comments for this article
    Deaths of despair
    Frederick Rivara, MD, MPH | University of Washington
    We are all concerned about the rise in so called deaths of despair, including suicide. This study shows that the rates of suicide have increased most readily in rural areas, especially this with the highest rates of deprivation. These findings are likely due in part to decreased availability of mental health services and higher rate of firearm ownership in these rural areas, both potentially modifiable risk factors.
    CONFLICT OF INTEREST: Editor in Chief, JAMA Network Open
    Social Capital
    Paul Nelson, M.D., M.S. | Family Health Care, P.C. retired
    Along with suicide mortality, our nation's population health is associated with several other forms of poor health that are related to Social Capital. They are maternal mortality, infant mortality, childhood obesity, adolescent homicide, substance addiction, homelessness, mass shootings, mid-life depression/disability, and decreasing longevity at birth (now 4 years in a row). In connection with these phenomena, here is another study that connects county by county prevalence of adult suicide with their community's Social Capital. Left unsaid is that Social Capital does not have a recognized, broadly accepted, and carefully defined definition. I direct your attention to the fourth paragraph in the Discussion segment of this Original Investigation.

    The actuarial profession recognizes that adversities account for 40% of the underlying causes of unstable health. The Millliman folks have published reports on this phenomenon. Robert D. Putnam Ph.D. spent his lifetime (in Italy as well as the USA) studying and reporting on Social Capital. The "Blue Zone" phenomena comes to mind as well. As one person's analysis of many versions for defining Social Capital, I offer the following two related definitions.

    Social Capital may be defined as the pervasive capability of a community's persons to apply the norms of trust, cooperation, and reciprocity for resolving the social dilemmas they encounter within their community's daily municipal life that becomes sustainable when their community's prevalence of generational Caring Relationships permeates their community's social networks. AND

    Caring Relationship may be defined as a variably asymmetric, social interaction occurring between two persons that begins with a beneficent goal to enhance each other's autonomy and flourishes from a timely obligation to communicate in harmony with warmth, non-critical acceptance, honesty, and empathy. NOTE: compassion occurs when warmth and empathy predominate within a prominently asymmetric, social interaction.
    Original Investigation
    September 6, 2019

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

    Author Affiliations
    • 1Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, Columbus
    • 2Rockefeller Neuroscience Institute, Behavioral Medicine and Psychiatry, West Virginia University, Morgantown
    • 3Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio
    • 4Departments of Pediatrics, Psychiatry, and Behavioral Health, The Ohio State University, Columbus
    • 5College of Social Work, The Ohio State University, Columbus
    • 6Department of Geography, The Ohio State University, Columbus
    JAMA Netw Open. 2019;2(9):e1910936. doi:10.1001/jamanetworkopen.2019.10936
    Key Points español 中文 (chinese)

    Question  What are the spatial and temporal trends in suicide rates, how are contextual-level factors associated with suicide, and do these associations vary across the rural-urban continuum?

    Findings  This cross-sectional study found that suicide rates in the United States increased from 1999 to 2016, with the greatest increase in rural counties. Deprivation had a disproportionately negative association with suicide rates in rural counties, the presence of gun shops and a higher percentage of uninsured individuals were associated with higher suicide rates, and high social capital was associated with lower suicide rates.

    Meaning  Understanding geographical differences in suicide rates and community-level risk and protective factors can inform development and implementation of targeted suicide prevention strategies.


    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.