Suicide among patients in the Veterans Affairs health system: rural-urban differences in rates, risks, and methods.

ABSTRACT

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.