I've been writing a lot about suicide in kids lately, first at The Upshot and then over at The Incidental Economist. We even did a Healthcare Triage that touched on new data. But a recent study and editorial in JAMA Pediatrics, "Widening Rural-Urban Disparities in Youth Suicides, United States, 1996-2010," is worth another look:
Importance Little is known about recent trends in rural-urban disparities in youth suicide, particularly sex- and method-specific changes. Documenting the extent of these disparities is critical for the development of policies and programs aimed at eliminating geographic disparities.Objective To examine trends in US suicide mortality for adolescents and young adults across the rural-urban continuum.
Design, Setting, and Participants Longitudinal trends in suicide rates by rural and urban areas between January 1, 1996, and December 31, 2010, were analyzed using county-level national mortality data linked to a rural-urban continuum measure that classified all 3141 counties in the United States into distinct groups based on population size and adjacency to metropolitan areas. The population included all suicide decedents aged 10 to 24 years.
Main Outcomes and Measures Rates of suicide per 100?000 persons.
Over the 15 years of this study, almost 66,600 youths died by suicide. The most startling finding (at least to me) was that the suicide rate in rural areas was almost twice that of urban areas. This held true for both males and females. Further, even after controlling for both individual and geographic variables, the gap between urban and rural suicide rates has been increasing.
Suicides by suffocation/hanging have been increasing (as noted in the TIE post). Firearm rates have gone down. However, the rates of both of these types of suicide were higher in rural areas, and the disparities have been worsening.
But trends only tell part of the story. More than half of all suicides committed during the study were by firearm. An accompanying editorial by JAMA Pediatrics editor Fred Rivara* makes a compelling argument that we've been ignoring suicide in our national debate on guns for too long.
First, he cites CDC data. In 2012, there were 33,363 deaths by firearms in the United States. But only 12,093 of these deaths were by homicide. About 62% of deaths by firearms, or 20,666 of them, were suicides. Guns are used far more often in suicides than homicides. He then cites research showing that access to guns can make an impulsive suicide attempt far more likely to succeed. Almost half of patients who have survived a suicide attempt report that the time between thinking about suicide and attempting is was 10 minutes or less.
People, especially kids, aren't always planning suicide. It's a spur of the moment decision. And having access to a gun can make things far worse. Guns work. Suicide attempts with a gun succeed more than 85% of the time; suicide attempts with poison or overdoses succeed less than 2% of the time. Meta-analyses show that there is a significant association between having access to a firearm and a higher chance of a suicide succeeding.
If someone wants to commit suicide, they can find a way, with out without access to a gun. That's very true. But certainly some could be prevented. Moreover, given the impulsivity of suicide attempts by youth, it's also possible that reducing access of youth to guns even without restricting the sale and ownership of guns by legal adults might make a difference--for example by increasing safe, locked storage apart from ammunition.
Rivara makes three recommendations as to how physicians can help:
In health supervision visits, inquire in a nonjudgmental tone whether firearms are present in the home. If the patient is depressed or has other signs of mental illness, the physician should make greater efforts to inquire about firearms in the home.
If firearms are present, forgo one’s personal philosophical beliefs about firearm ownership and concentrate on the pragmatic matter of safe storage.
Participate in community efforts to promote safe storage of firearms. The success of community campaigns is enhanced by the authoritative voices of police officers who are enlisted as spokespersons on gun safety.
Many have long advocated for these. Yet, recent efforts have made it illegal for physicians to even ask about guns at all in some areas of the country. I think that's a mistake, as I argued here at The Upshot. We need to continue in our efforts at harm reduction, and continue to work towards making suicide rarer among youth in the United States.
*Full disclosure: The pediatric health services research world is small. Fred is a longtime mentor and friend (I trained with him in Seattle), and I serve on the editorial board of JAMA Pediatrics.