The proportion of suicides by shooting is considerably lower in urban areas - and this disparity for rural counties has become bigger in recent years.
The number of suicides in the US, among the age group that includes all children from the age of 10, up to all young adults to the age of 24, were collated by county and put through a statistical analysis for research published in JAMA Pediatrics.
A higher rate in the most rural counties was by a factor of 2.05 for males compared with the most urban areas in 1996-1998 - and this rural differential rose in 2008-2010, to 2.69 times the rate in urban areas for male suicide deaths committed by gun.
Across all the years 1996-2010 covered by the analysis, overall suicide disparity was shown by:
- For males, rural suicide rates being almost twice those of urban ones (19.9 vs. 10.3 per 100,000 population)
- A similar disparity for females among their fewer suicides overall (4.4 rural vs. 2.4 urban per 100,000).
Some 51.1% of all the suicides were by firearm and most of the remaining, 33.9%, were by hanging/suffocation; methods of poisoning accounted for 7.9%, and 7.1% were by other means.
Mapping urban and rural life in the US
The updated comparison of rural and urban youth suicides is produced by Cynthia Fontanella, PhD, of the Ohio State University Wexner Medical Center in Columbus.
With her co-authors, Dr. Fontanella worked out the comparative rates from the latest US data on deaths by mapping these against an existing detailed picture of rural and urban geography.
All the 3,141 counties of the US had been put into categories that describe how rural or urban they are in the nine groupings set out in the map from the US Department of Agriculture.
These "RUCC codes" assign counties into one of nine groups by population number and adjacency to metropolitan areas. There are three "metro county" groups - the most urban of which have populations of over a million people; and the two most rural categories among the six "nonmetro" county types have populations below 2,500 or are completely rural.
Rural disparity, firearms controversy
The authors find that while there were, overall, disproportionately higher rates of suicide in rural areas, as shown in a combination of those from firearms with those from hanging/suffocation, suicide rates from firearms actually fell with a rise in rates by hanging/suffocation.
The opinion of Dr. Frederick Rivara regarding gun risks is clear, however. Cutting through the statistics, Dr. Rivara gives this summary in an editorial accompanying the JAMA paper:
"Among both males and females, suicide rates in rural areas were much higher than rates in urban areas, driven in part by the higher rate of gun-related suicides in rural areas of the country."
Dr. Rivara notes: "The prospects for resolution of the ideological struggle in the US regarding firearm ownership remain remote." However, he says:
"Safe storage of firearms in the homes of children or others at risk for suicide is a pragmatic rather than ideological issue that should not be contentious."
Access to a means for suicide appears to be a strong risk factor, the editorial points out. It also cites evidence that many suicide attempts are impulsive acts. The time from formulating and then coming to the point of acting on a decision takes under 10 minutes, Dr. Rivara argues, citing data from suicide survivors' reports.
Dr. Rivara - as editor of JAMA Pediatrics and a professor of child pediatrics practising at The Child Health Institute of the University of Washington in Seattle, WA - writes that "access to firearms turns an attempt into a fatality" - the study cited suggests that such suicide attempts result in death 86% of the time.
With the debate about access to means of suicide come questions about the reasons for it, and the authors of the study speculate on several factors behind the growing rural disparity of suicide among young people. In particular, they pick out the following potential reasons in rural areas:
- Limited availability of mental health services
- Geographic and social isolation
- More common ownership and use of firearms
- Changing socio-demographic and economic factors.
On the question of mental health provision, Dr. Rivara is worried about the "failure" of physicians to raise the issue of access to guns even when young people have been identified as at risk because of mental health issues.
He tells doctors, for example, to forgo "philosophical beliefs about firearm ownership and concentrate on the pragmatic matter of safe storage."
Dr. Rivara says:
"Most concerning is that adolescents with a history of mental illness and those with a history of suicidality were as likely to report access to guns kept in the home as were those without such histories."
Major cause of death among American youngsters
The authors' analysis used data on causes of death held by the US Centers for Disease Control and Prevention (CDC) and publicly available via its Wonder databases online.
Young people are, of course, more likely to die from causes related to mental health, accidents, and so on, than from "organic" disease. To put the research paper's data on suicide rates into perspective, here is a comparison with the other main causes for the 15-24 years age group.
Using the detailed mortality tool to run a search for all causes of death among 15- 24-year-olds, and ticking each year from 2006-10, pulls up the full list of data for deaths.
The highest rates of death in these youngsters are from the following top 8 causes, with the highest proportion shown first (the definitions are those of the World Health Organization):
- Assault "by other and unspecified firearm discharge" - 8.8 deaths per 100,000 population
- Person injured in unspecified motor-vehicle accident, traffic - 6.5
- Intentional self-harm by hanging, strangulation and suffocation - 3.8
- Accidental poisoning by, and exposure to, narcotics and psychodysleptics (hallucinogens) - 3.4
- As 4. But by unspecified drugs, medicaments and biological substances - 3.0
- Intentional self-harm by other and unspecified firearm discharge - 2.8
- Person injured in collision between other specified motor vehicles (traffic) - 1.7
- Car occupant injured in collision with fixed or stationary object, driver injured in traffic accident - 1.4.
For each cause in this list, the young age group accounts for virtually all of the total US deaths - in other words, such causes are behind a relatively tiny percentage of deaths in people outside of this group of 15- to 24-year-olds.