Discussion

During 2001–2015, age-adjusted suicide rates for nonmetropolitan/rural counties were consistently higher than for medium/small and large metropolitan counties. Although other studies have documented these differences (10), this report examined annual changes in rates by urbanization level along with trends among and within urbanization levels by sex, race/ethnicity, age group, and mechanism of death. A closer look at annual rate changes revealed substantial increases after 2005 for large metropolitan counties, after 2008 for medium/small metropolitan counties, and after 2007 for nonmetropolitan/rural counties. Although the Great Recession officially began in 2007 and ended in 2009 (14), differential effects were observed at different points in different geographic areas (14). Economic indicators (e.g., housing foreclosures, poverty, and unemployment) vary by urbanization level, with rural areas usually having greater prevalence of these negative factors (15). Factors such as housing foreclosures and overall business cycles negatively affect suicide rates and other health outcomes (16–18). A combination of these factors likely contributed to the differences in annual suicide rate changes by urbanization level observed in this study. In addition, because U.S. suicide rates were increasing before the Great Recession, other contributors to the changes in rates were likely (19).

The differences observed in suicide rates by sex within urbanization levels are consistent with previous findings that age-adjusted suicide rates tend to be higher for men than for women (3). This difference is maintained regardless of urbanization level, with differences most notable in nonmetropolitan/rural counties. By race/ethnicity, age-adjusted suicide rates for non-Hispanic American Indian/Alaska Natives are consistently the highest, followed by rates for non-Hispanic whites across all periods; however, when comparing rates by race/ethnicity across urbanization levels, suicide rates are highest for non-Hispanic whites in metropolitan counties and for non-Hispanic American Indian/Alaska Natives in nonmetropolitan/rural counties.

CDC released a technical package of policies, programs, and practices to prevent suicide that includes examples of programs that can be tailored to fit the cultural needs of different racial/ethnic groups (20). The technical package is a compilation of a core set of strategies, developed using the best available evidence, that have the greatest prevention potential. For example, a suicide prevention program called Sources of Strength was developed with rural and tribal communities in North Dakota to promote connectedness between youth and adults. The program strategy is to understand and respond to underlying causes of suicidal behavior and promote protective factors against suicidal behavior to prevent adverse outcomes. Sources of Strength is a universal (i.e., programs administered to all children in classrooms regardless of individual risk status) school-based approach to suicide prevention that is designed to build socioecological protective influences across the student population. Youth opinion leaders are recruited from diverse social backgrounds, including some who are at risk for suicidal behavior. They are trained to change the norms and behaviors of their peers by conducting well-defined messaging activities with adult mentoring (21). Local implementers might need to tailor this and other programs discussed in CDC’s technical package for suicide prevention to specific cultural practices and traditions of tribes in rural areas.

Another notable finding regarding racial/ethnic differences by urbanization level was identified from analysis of the total age-adjusted rates by urbanization level across the study period. For non-Hispanic blacks, suicide rates do not follow the historical trend of being highest in rural areas. Except during 2004–2006, rates for non-Hispanic blacks in rural areas were consistently lower than rates for non-Hispanic blacks in urban areas, with fluctuations across the entire period. A previous study using data from the 1993 National Mortality Followback Survey to identify risk and protective factors specific to suicide among blacks identified rural residence as a protective factor (22). A hypothesis that has been proposed to support this finding is that blacks living in urban areas will be more at risk for suicide due to the stressors and strains of urban life, including unaccustomed social isolation, as well as difficulty acculturating to middle-class suburban living (22).

Findings by age group among urbanization levels revealed increases in rates for all age groups, with the highest rates and greatest rate increases in more rural areas. Within all urbanization levels, the highest rates were observed among persons aged 35–64 years. This age group has been of particular interest given increases in suicide rates among middle-aged whites (23). Findings are consistent with those of studies that have identified a pattern of increasing mortality among non-Hispanic white populations, which is in part attributed to increases in drug overdoses, suicides, and alcohol-related mortality, especially among persons aged 45–54 years (24). By mechanism of death within each urbanization level, firearms were the most common, with the highest rates and greatest rate increases in rural areas. Among urbanization levels, rates for firearms as the mechanism of death in nonmetropolitan/rural counties were approximately two times the rates of those in metropolitan counties. This might be attributed, in part, to firearm ownership being more common in rural areas and a large number of rural community residents being familiar with firearm use (25).

Suicide rates by sex, race/ethnicity, age group, and mechanism of death for the general population are higher in rural communities than in urban areas. In addition to considering differences by sex, race/ethnicity, age group, and mechanism of death, this study underscores the need for analyses both among and within urbanization levels with the goal of designing and implementing tailored suicide prevention efforts. To address suicide in rural areas, the Health Resources and Services Administration has developed activities including epidemiologic studies, research, and programs for primary health care providers. Ongoing work by CDC in suicide prevention from a public health perspective, such as programs that focus on middle-aged men, a group experiencing one of the greatest increases in suicide rates (3), is an important step in decreasing overall suicide rates in the United States. Prevention practitioners could use these findings to prioritize and allocate resources for their rural populations as part of efforts to meet the Healthy People 2020 goal to reduce the suicide rate by 10% (4).