Suicide Prevention: Determining the Importance of Place

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Suicide Prevention Determining the Importance
of Place

• Christian L. Hanna, MPH
• Childrens Safety Network

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Objectives

• Understand the role of place plays in suicide
• Recognize patterns by place associated with
  suicide
• Review evidence for suicide discrepancies by
  place in the U.S.
• Discuss state distribution of suicide
• Suggest countermeasures and approaches
• Questions?

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Science of Epidemiology

• Study of events rooted in the assumption that
  events do not occur in a random fashion

• Person
• Place
• Time

Understand risk and target interventions
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Epidemiology of Suicide

• PERSON
• Age
• Gender
• Race
• Method
• Outcomes
• Location
• Risk factors

• TIME
• Day
• Month
• Time of day
• Season

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Place
Hot spots
Urban
Rural
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Person, Time, Place

• So what?
• Not often amenable to interventions
• Focus interventions
• Definitions and Diversity
• Lack of data
• Generalization and stereotypes
• Low base rate

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Place as a Source
Broad Street Pump London, 1854

• Place plas n. a particular part of space a spot
  a locality a building
• L. platea, a broad street

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Normal and Random Distribution
if place didnt matter?
Low Medium High
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History of Place

• SSocial factors and social integration of
  individuals exert a powerful influence over
  suicidal behaviorbroad social forces account for
  the variation in suicide rates. Suicide 1897

Emile Durkheim
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Nels Sanddal Critical Illness and Trauma
Foundation Bozeman, MT.
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What is Rural?

• USDA Rural Urban Continuum Codes
• http//www.ers.usda.gov/Data/RuralUrbanContinuumCo
  des/

• No less than 12 official designations of
  rural/non-metropolitan
• Population density
• Physical location
• Cultural
• Climate
• Economics
• Legal/political
• Access to services
• Funding

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Epidemic of Suicide in Rural Places

• China
• Greece
• Australia
• New Zealand
• Ireland
• Sweden
• Scotland

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Patterns of Injury Mortality

Fire/burn
Falls

75th percentile (RED) 50th but less than the 75th
percentile (BLUE) 25th but less than the 50th
percentile (GRAY) Less than the 25th percentile
(WHITE)
89-98
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All suicide, 1989-1998
75th percentile (RED) 50th but less than the 75th
percentile (BLUE) 25th but less than the 50th
percentile (GRAY) Less than the 25th percentile
(WHITE)
89-98
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Suicide by Age
65-85
10-19
75th percentile (RED) 50th but less than the 75th
percentile (BLUE) 25th but less than the 50th
percentile (GRAY) Less than the 25th percentile
(WHITE)
89-98
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Suicide by Method
Firearm
75th percentile RED 50th but less than the 75th
percentile BLUE 25th but less than the 50th
percentile (GRAY) Less than the 25th percentile
(WHITE)
Suffocation
Poisoning
89-98
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What are the factors of rural states and counties
with higher suicide rates?

• Geographic
• Demographic
• Access to Means
• Data Collection
• Access to Care
• Behavioral and Attitudinal culture
• Socioeconomic

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Evidence for Suicide in Rural U.S.
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Suicide Behaviors

• Youth suicide risk behaviors by place of
  residence
• Youth Risk Behavior Surveillance System-CDC
  1997/1999
• No significant differences in suicide behaviors
  (ideation, planning, attempts, or injury) of
  nonmetropolitan adolescents.

Marlenga Hanna Unpublished data
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Suicide Mortality

• Adolescent suicide by place of residence
• Death Certificate Data-NCHS 1979-1995
• Suicide rates for 15-19 year olds in
  nonmetropolitan areas are significantly higher
  since 1989.

Marlenga Hanna Unpublished data
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Increasing rural-urban gradients in US suicide
mortality, 1970-1997.

• Rural men have twice the suicide rate of their
  urban counterparts.
• Suicide rates for young women were 85 higher in
  rural
• Suicide rates for working-age women were 22
  higher in rural.
• Widening rural-urban differentials in male
  suicides over time.

Singh GK, Siahpush M. The increasing rural urban
gradient in US suicide mortality, 1970,-1997 Am J
Public Health. 2003 July 200393(5)1161-1167
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Singh GK, Siahpush M. The increasing rural urban
gradient in US suicide mortality, 1970,-1997 Am J
Public Health. 2003 July 200393(5)1161-1167
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Acute Traumatic Injuries in Rural Populations

• Suicide rates were 31 - 43 higher in
  nonmetropolitan counties
• Suicide rates were 80 higher in rural Western
  U.S. among male residents

Peek-Asa, Corinne PhD, MPH Zwerling, Craig PhD,
MD, MPH Stallones, Lorann PhD, MPH Acute
Traumatic Injuries in Rural Populations AJPH
Volume 94(10)   October 2004   1689-1693
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Urban-Rural Shifts in Intentional Firearm Death
Different Causes, Same Results
Intentional Firearm and Intentional Nonfirearm
89-98
Branas CC, Nance ML, Elliott MR, Richmond TS,
Schwab CW. (2004).Urban-Rural Shifts in
Intentional Firearm Death Different Causes, Same
Results. AJPH, 9410, 1750-1755
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Firearm Suicide and Homicide
89-98
Branas CC, Nance ML, Elliott MR, Richmond TS,
Schwab CW. (2004).Urban-Rural Shifts in
Intentional Firearm Death Different Causes, Same
Results. AJPH, 9410, 1750-1755
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Nonfirearm Suicide and Homicide
flat
89-98
Branas CC, Nance ML, Elliott MR, Richmond TS,
Schwab CW. (2004).Urban-Rural Shifts in
Intentional Firearm Death Different Causes, Same
Results. AJPH, 9410, 1750-1755
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Predicting Suicide Rates Using State-Level
Ecological Models Implications for Prevention

• State level data were collected for variables
  hypothesized to be related to suicide.

• Positive correlation
• Unintentional injury
• Households firearms
• Drug and alcohol measures
• Income disparities
• Youth suicides
• AI/AN
• No correlation
• Income
• Population density
• Legalized gambling
• Alcohol/drug use

Fullerton-Gleason L., Personius J, LaValley,
Shires GT, 2005 National Injury Prevention and
Control Conference, May 2005, Abstract book page
82
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Suicide, by county
http//www.cdc.gov/ncipc/maps/default.htm
Red 75th national percentile Blue 50th national
percentile Gray 25th national percentile White
lt25th national percentile
89-98
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Maine
Red 75th national percentile Blue 50th national
percentile Gray 25th national percentile White
lt25th national percentile
89-98
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New Hampshire
Red 75th national percentile Blue 50th national
percentile Gray 25th national percentile White
lt25th national percentile
89-98
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Connecticut
Red 75th national percentile Blue 50th national
percentile Gray 25th national percentile White
lt25th national percentile
89-98
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New York
Red 75th national percentile Blue 50th national
percentile Gray 25th national percentile White
lt25th national percentile
89-98
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New Jersey
Red 75th national percentile Blue 50th national
percentile Gray 25th national percentile White
lt25th national percentile
89-98
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Massachusetts
Red 75th national percentile Blue 50th national
percentile Gray 25th national percentile White
lt25th national percentile
89-98
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Vermont
Red 75th national percentile Blue 50th national
percentile Gray 25th national percentile White
lt25th national percentile
89-98
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Rhode Island
Red 75th national percentile Blue 50th national
percentile Gray 25th national percentile White
lt25th national percentile
89-98
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Countermeasures-Suicide Prevention in Rural
Places Broad Street Pump

• Surveillance
• Access and availability of firearms
• Mental health services- help seeking behaviors?
• Stigma and isolation

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Conclusion

• Does place matter?

?
I'm wondering if you know of any research that
supports our thinking that there is a greater
impact when a youth suicide occurs on youth and
community members in a rural area (because
everyone knows each other) than in urban areas?
Cheryl DiCara Maine Injury Prevention Program
and Maine Youth Suicide Prevention Program
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Best Practices for Rural

• Be a good neighbor
• Respect diversity of communities
• Use a comprehensive approach
• Understand help seeking behaviors
• Provide services in nontraditional settings

• Understand local needs and respond accordingly
• Protect confidentiality
• Address lethal means
• Do not ignore stigma
• Fight complacency and stigma
• Enhance treatment capacity

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The landmarks of political, economic, and social
history are the moments when some condition
passed from the category of the given into the
category of the intolerableI believe that the
history of public health might well be written as
a record of successive re-defining of the
unacceptable. Geoffrey Vickers,
What sets the goals of public health? Lancet,
1958
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www.advancingsp.com
Rural Suicide July 2005
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Contact Information

• www.childrenssafetynetwork.org
• www.sprc.org
• Chris Hanna
• hanna.chris_at_mcrf.mfldclin.edu
• 800-662-6900