The role of race in rural‐urban suicide disparities

Abstract

Purpose To assess the role that race‐ethnicity plays in modifying the observed rural‐urban disparity in suicide among Veteran Health Administration (VHA) users. Methods We performed a retrospective cohort study of 10,737,864 VHA users between 2003 and 2017, using cross‐linked VHA medical records and National Death Index mortality data to assess longitudinal race‐stratified rural‐urban differences in age‐ and sex‐adjusted annual suicide rates. We used Poisson regression and generated incident rate ratios (IRRs) to formally assess the impact of race on the rural‐urban suicide disparity. Given evidence of effect modification, we performed additional race‐stratified Poisson regression models. Findings Rurality is significantly associated with a higher risk of suicide in models which do not control for race (IRR = 1.14, 95% CI: 1.10‐1.17). However, when race is added to the model, rural residence is no longer significant (0.98, CI: 0.95‐1.01). Stratified models demonstrate that rural residence is significantly associated with a higher suicide risk among Hispanic VHA users (1.41, CI: 1.11‐1.79), but it is not substantially associated with suicide among White (0.97, CI: 0.94‐1.00) and Black (1.03, CI: 0.86‐1.23) VHA users. White VHA users have considerably higher suicide rates than Black and Hispanic VHA users, though the suicide rate among Hispanic VHA users, particularly those in rural settings, increased markedly over the period of observation. Conclusions Race significantly modifies the relationship between rural residence and suicide risk. Studies seeking to assess suicide disparity between rural and urban VHA user populations must include adjustment or stratification by race.

Examination of increasing suicide rates among rural Hispanic VA patients

“…In conclusion, rural Hispanic VA patients have a higher suicide rate than urban Hispanic VA patients. This is in contrast to our prior findings in non‐Hispanic VA patients, where the rural‐urban disparity in suicide was more easily explained by rural‐urban differences in sex and race 7 . Individual mental health diagnoses were the most important predictors of suicide among rural Hispanic VA patients and the rate of these disorders is increasing.…”

“…We recently performed a series of national studies to better understand the drivers of the rural‐urban disparity in suicide mortality among patients of the US Department of Veterans Affairs (VA). We found that rural VA patients were more likely to be non‐Hispanic White and male than urban VA patients and that the concentration of demographic risk factors in rural settings drove the disparity 6,7 . Furthermore, we found that individual risk factors, such as race, sex, and mental health diagnoses, mattered far more than rural‐urban contextual differences in predicting death by suicide among VA patients 6,8 .…”

“…We found that rural VA patients were more likely to be non-Hispanic White and male than urban VA patients and that the concentration of demographic risk factors in rural settings drove the disparity. 6,7 Furthermore, we found that individual risk factors, such as race, sex, and mental health diagnoses, mattered far more than rural-urban contextual differences in predicting death by suicide among VA patients. 6,8 A concerning observation was a rapidly increasing rate of suicide mortality among Hispanic VA patients, particularly those living in rural settings.…”

“…Furthermore, we found that individual risk factors, such as race, sex, and mental health diagnoses, mattered far more than rural‐urban contextual differences in predicting death by suicide among VA patients 6,8 . A concerning observation was a rapidly increasing rate of suicide mortality among Hispanic VA patients, particularly those living in rural settings 7 . The suicide mortality rate among rural Hispanic VA patients increased from approximately 10 per 100,000 population in 2003‐2005 period to approximately 30 per 100,000 population by 2015‐2017.…”

“…6,8 A concerning observation was a rapidly increasing rate of suicide mortality among Hispanic VA patients, particularly those living in rural settings. 7 The suicide mortality rate among rural Hispanic VA patients increased from approximately 10 per 100,000 population in 2003-2005 period to approximately 30 per 100,000 population by 2015-2017. Furthermore, the adjusted incident rate ratio (RR) for suicide was 41% higher for rural Hispanic VA patients compared to their urban counterparts.…”