摘要：Objectives . Using national patient cohorts, we assessed rural–urban differences in suicide rates, risks, and methods in veterans. Methods . We identified all Department of Veterans Affairs (VA) patients in fiscal years 2003 to 2004 (FY03–04) alive at the start of FY04 (n = 5 447 257) and all patients in FY06–07 alive at the start of FY07 (n = 5 709 077). Mortality (FY04–05 and FY07–08) was assessed from National Death Index searches. Census criteria defined rurality. We used proportional hazards regressions to calculate rural–urban differences in risks, controlling for age, gender, psychiatric diagnoses, VA mental health services accessibility, and regional administrative network. Suicide method was categorized as firearms, poisoning, strangulation, or other. Results . Rural patients had higher suicide rates (38.8 vs 31.4/100 000 person-years in FY04–05; 39.6 vs 32.4/100 000 in FY07–08). Rural residence was associated with greater suicide risks (20% greater, FY04–05; 22% greater, FY07–08). Firearm deaths were more common in rural suicides (76.8% vs 61.5% in FY07–08). Conclusions . Rural residence is a suicide risk factor, even after controlling for mental health accessibility. Public health and health system suicide prevention should address risks in rural areas. Suicide among veterans is a national concern, 1,2 and suicide prevention is a priority for the US Department of Veterans Affairs (VA) health system, the Veterans Health Administration. The VA provides health services to approximately 5.5 million veterans each year, more than one fifth of all veterans. The VA serves a patient population with important suicide risk factors. Patients are predominantly male and older, and often have substantial physical morbidities, substance use problems, and mental illnesses. 3–5 Also, VA patients are more likely to reside in rural settings than is the general US population. 6,7 This trend is expected to continue because rural residents are overrepresented among military recruits. In 2005, although 7.6% of 18- to 24-year-old US residents lived in rural areas, 11.8% of 18- to 24-year-old military recruits were from these areas. 8 Research is needed to assess whether rural residence is associated with differential suicide rates and risks among the national population of VA patients. Since the early 1970s, suicide rates among men in rural areas of the United States have exceeded those of urban men, and rural–urban differentials have increased for both genders. 9,10 Similar trends have been observed outside of the United States. 11–13 Elevated suicide rates in rural areas have been attributed to factors including geographic and interpersonal isolation, economic and social distress, and rural culture. 14 Rural populations are smaller and more dispersed, potentially limiting opportunities for social integration and social support. Geographic accessibility of mental health treatment resources is often diminished, with providers fewer and farther between. Economic declines may affect rural areas more drastically. Further, rural agrarian cultural values, which champion a strong work ethic, independence, and self-reliance, may inhibit treatment-seeking behavior. 15 Previous research on suicide risks associated with veteran status among community residents produced mixed results. 16–20 Among male respondents to the US National Health Interview Survey, suicide risks between 1986 and 1997 for male veterans were found to be twice those of male nonveterans (adjusted hazard ratio [HR] for veterans = 2.04; 95% confidence interval [CI] = 1.10, 3.80), controlling for rurality of residence. 19 However, in an analysis of middle-aged and older men who participated in a large prospective cohort study from 1982 to 2004, which did not adjust for rurality, veteran status was not associated with suicide risk. 20 In their review, Kang and Bullman noted that “historically the rates of suicide among veterans in general have been lower than that of the US population.” 18 (p 760) To date, however, few studies have adjusted for rurality, 19 and it is important to consider rural–urban differentials in risks among veterans. Among VA patients, research suggested that suicide rates were greater than those in the general US population. Before the conflicts in Afghanistan and Iraq, and before recent VA health system initiatives, the standardized mortality ratio for suicides among male VA patients in 2001 was 1.66 compared with men in the general US population; for female patients, it was 1.87. 21 Elevated risks among VA patients might reflect the fact that they represent a treatment-seeking population with substantial medical and psychiatric morbidities and meeting eligibility requirements means testing, based on income thresholds, or military service-related disability status. 22 Currently, little is known about rural–urban differences in suicide risks among VA health system users. However, if consistent with general trends in the United States, 9,10,14 suicide risks may well be greater for VA patients residing in rural areas compared with those in urban areas. Studies indicated that VA patients in rural areas had more physical comorbidities and worse health-related quality of life than those in suburban or urban areas, 23 and that they had reduced access to health services and fewer alternatives to VA care. 24 Access barriers might limit receipt of needed health services and continuity of care, 25 and this might exacerbate suicide risks. Another factor that may relate to differential suicide risks is access to lethal means of suicide, notably firearms. Among suicide attempt methods, firearms have the highest case fatality rate (suicides/[suicides + nonfatal injuries due to self-harm]): 84% in the United States during 2002 to 2006. 26 In non-VA populations, method of suicide differs across rural–urban settings. State-level analyses indicated that higher firearm ownership was associated with increased rates of firearm suicides, 26 and suicide deaths among veterans were more likely to involve firearms than those among nonveterans. 19,28 Between 2002 and 2006, although firearms were the most common method among male suicide decedents in the United States (58%), poisoning was the most common method among female suicide decedents (39%). 26 To date, little is known regarding potential rural–urban differences in means of suicide among VA patients, overall or by gender. The objectives of this study were to examine rural–urban differences in rates, risks, and methods of suicide among the population of individuals receiving services in the VA health system. We hypothesized that VA patients in rural areas and those residing farther from VA mental health facilities were at greater risk for suicide, and that method of suicide differed by rural–urban status. Further, we examined 2 periods of time to assess potential differences over time. Research in this area might inform health services organization and delivery and advance assessments of whether and how veteran status relates to suicide risks.
