Results

The most recent overall suicide rates (representing 2014–2016) varied fourfold, from 6.9 (District of Columbia) to 29.2 (Montana) per 100,000 persons per year (Supplementary Table; https://stacks.cdc.gov/view/cdc/53785). Across the study period, rates increased in all states except Nevada (where the rate was consistently high throughout the study period), with absolute increases ranging from 0.8 per 100,000 (Delaware) to 8.1 (Wyoming). Percentage increases in rates ranged from 5.9% (Delaware) to 57.6% (North Dakota), with increases >30% observed in 25 states (Supplementary Table; https://stacks.cdc.gov/view/cdc/53785) (Figure).

Modeled suicide rate trends indicated significant increases in 44 states, among males (34 states) and females (43 states), as well as for the United States overall (Supplementary Table; https://stacks.cdc.gov/view/cdc/53785). Nationally, the model-estimated average annual percentage change for the overall suicide rate was an increase of 1.5%. By sex, estimated national rate trends further indicated significant average annual percentage change increases for males (1.1%) and females (2.6%) (Supplementary Table; https://stacks.cdc.gov/view/cdc/53785).

Suicide decedents without known mental health conditions (11,039; 54.0%) were compared with those with known mental health conditions (9,407; 46.0%) for 27 states. Whereas decedents were predominantly male (76.8%) (Table 1) and non-Hispanic white (83.6%), those without known mental health conditions, relative to those with mental health conditions, were more likely to be male (83.6% versus 68.8%; odds ratio [OR] = 2.3, 95% CI = 2.2–2.5) and belong to a racial/ethnic minority (OR range = 1.2–2.0). Suicide decedents without known mental health conditions also had significantly higher odds of perpetrating homicide followed by suicide (aOR = 2.9, 95% CI = 2.2–3.8). Among decedents aged ≥18 years, 20.1% of those without known mental health conditions and 15.3% of those with mental health conditions had previously served in the U.S. military or were serving at the time of death.

Whereas firearms were the most common method of suicide overall (48.5%), decedents without known mental health conditions were more likely to die by firearm (55.3%) and less likely to die by hanging/strangulation/suffocation (26.9%) or poisoning (10.4%) than were those with known mental health conditions (40.6%, 31.3%, and 19.8%, respectively). These differences remained significant in the adjusted models.

Toxicology testing was less likely to be performed for decedents without known mental health conditions. Among those with toxicology results, decedents without known mental health conditions were less likely to test positive for any substance overall (aOR = 0.8, 95% CI = 0.7–0.8), including opioids (aOR = 0.90, 95% CI = 0.81–0.99), but were more likely to test positive for alcohol (aOR = 1.2, 95%, CI = 1.1–1.3).

Information on circumstances surrounding suicide were available for all decedents with mental health conditions (9,407) and approximately 85% of those without known mental health conditions (9,357) in 27 states (Table 2). Persons without known mental health conditions were less likely to have any problematic substance use (aOR = 0.7, 95% CI = 0.7–0.8) than were persons with known mental health conditions. Whereas two thirds of decedents with known mental health conditions had a history of mental health or substance use treatment (67.2%), just over half (54.0%) were in treatment at the time of death.

Decedents without known mental health conditions had a significantly higher likelihood of any relationship problem/loss (45.1%) than did those with known mental health conditions (39.6%), specifically intimate partner problems (30.2% versus 24.1%), arguments/conflicts (17.5% versus 13.6%), and perpetrating interpersonal violence in the past month (3.0% versus 1.4%). Decedents without known mental health conditions were also more likely than were those with known mental health conditions to have experienced any life stressors (50.5% versus 47.2%) such as recent criminal legal problems (10.7% versus 6.2%) or eviction/loss of home (4.3% versus 3.4%) and were more likely to have had a recent or impending (within the preceding or upcoming 2 weeks, respectively) crisis (a current or acute event thought to contribute to the suicide) (32.9% versus 26.0%). All of these differences remained significant in the adjusted models. Physical health problems and job/financial problems were commonly contributing stressors among both persons without mental health conditions (23.2% and 15.6%, respectively) and those with mental health conditions (21.4% and 16.8%, respectively). Similarly, among all persons with recent crises, intimate partner problems were the most common types and did not differ by group.

Decedents without known mental health conditions had significantly lower odds of recent release from any institution (aOR = 0.5, 95% CI = 0.4–0.5). Among those recently released, decedents without known mental health conditions were significantly more likely than decedents with mental health conditions to have been released from a correctional facility (25.7% versus 8.7%), hospital (43.7% versus 33.0%), or other facility, such as an alcohol/substance use treatment facility (24.2% versus 11.6%). Among decedents with known mental health conditions who were recently released from an institution, 46.7% were released from psychiatric facilities.

Decedents without known mental health conditions were significantly less likely to have a history of suicidal ideation (23.0%) or prior suicide attempts (10.3%) compared with those with known mental health conditions (40.8% and 29.4%, respectively). Suicide intent was disclosed by 22.4% and 24.5% of persons without and with known mental health conditions, respectively.