Suicide kills approximately 85 Americans per day and 30,000 Americans annually (U.S. Public Health Service, 1999). According to Jamison (1999), in the United States during 1995, "more teenagers and young adults died from suicide than died from cancer, heart disease, AIDS, pneumonia, influenza, birth defects, and stoke combined." In 1996, the suicide rate for the United States was 10.8 per 100,000 population (U.S. Public Health Service, 1999). A recent World Health Organization report shows that among persons between the ages of fifteen and forty-four, suicide is the second leading cause of death among females and the fourth leading cause of death among males world-wide (Jamison, 1999).
In 1897 Emile Durkheim, in his classic study Suicide, proposed that social factors exert a powerful influence over individual behavior, even behavior as personal as suicide. While we understand a great deal more about suicide today and recognize that mental illness is the single most prevalent underlying factor in suicide, there is still variation in the rate of suicide that we do not completely understand.
One of the significant sources of variance in suicide rates is place of residence, specifically rural-urban differences. Data from the Centers for Disease Control indicate that in every region in the United States and for the country as a whole, the rate of suicide deaths is higher in nonmetropolitan areas compared to metropolitan areas (see Tables 1 and 2). This holds true for both adults and children. This data also reflects trends found in other research that shows that suicide rates are much greater in the "frontier" states of the mountain west and Great Plains. Some of the highest rates (per 100,000) for suicide among 15-19 year olds during the period of 1992-1996 were found in Alaska (31), Wyoming (23), Montana (22), South Dakota (21), North Dakota (20), New Mexico (19), Utah (19), Arizona (17), Nevada (16), Idaho (15), Colorado (15), and Kansas (15) (Centers for Disease Control Compressed Morbidity Files). Wallace et al. (1996) reports that from 1979 to 1992 Native American adolescent and young adult males living in Indian Health Service Areas (predominately rural) had the highest suicide rate (62.0 per 100,000) in the nation. In a study of northeastern counties of the United States for the period of 1973 to 1977, Wilkson and Isreal (1984) found a strong positive association between rurality and suicide rates.
These rural-urban differences in suicide rates, however, have not been consistent over the years. Stack (1982) found that early in the past century, suicide rates were higher in urban areas, but by mid-century there was essential parity, and toward the end of the century rates were higher in rural areas. Analysis of data from the 1980 national mortality statistics indicated that after controlling for differences in age, sex, and race, rural areas had slightly lower rates of suicide compared to urban areas (Office of Technology Assessment, 1990). Confounding these comparisons is the argument that suicides are more likely to be underreported in rural areas than in urban areas.
These rural-urban differences in suicide are not just an U.S. phenomenon. In Australia the suicide rate for 15-24 year olds was 33.9 per 100,000 for rural males compared to 23.6 per 100,000 for urban males (National Rural Health Alliance, 1998). In China the suicide rate in rural areas is three times that of urban areas (Neal, 1998). China is also the only country that reports more suicides by women than men and in 1990 accounted for 40 percent of the world's suicide deaths (Jamison, 1999). In Greece rural suicide rates were twice as high as urban rates (Zacharakis et. al, 1998).
There also appears to be differences in patterns of suicide between urban and rural areas. Jamison (1999) reports suicide rates to have "greater seasonality in rural areas than in urban areas." Gunderson et al. (1993) found that farmers and ranchers were more likely to commit suicide on Sunday mornings than any other time of the week. This is in contrast to the peak periods of suicidal behavior by the general public of Friday and Saturday nights. Farmers are also more likely to commit suicide during the periods of planting (spring) or harvest (fall). Rosmann (2000) explores these and other factors on farm suicide.
Rural occupations, such as farming, appear to be a risk factor in rural suicide. Gunderson et al. (1993) in a study of suicide in five north-central states reports the rate of suicide among farmers and ranchers as ranging from 42 to 58 suicides per 100,000. These high rates are consistent with other studies of suicide among England and Wales (Kelly and Charlton, 1995), Canadian (Morrison et al., 1992), Kentucky (Stallones, 1991), and Wisconsin (Saftlass et al., 1987) farmers. There is, however, some contradictory evidence in a study of Colorado farmers (Stallones, 1991).
There is a lot of informal speculation on the possible reasons for the generally higher rate of suicide in rural areas, but there is little definite evidence. Rural stress, especially related to the "farm crisis" is an often-cited rationale (Ortega, et. al, 1994). Overwhelming and continuing experiences of loss (loss of land, loss of political power, loss of livelihood, loss of community, loss of a way of life) have also been put forth as contributing factors. Perhaps one of the most obvious explanations, given that one of the biggest risk factors for suicide is untreated mental disorder, is the lack of access to mental health services and the shortages of specialized mental health practitioners in rural areas. Social isolation is another often-cited factor. More recently there has been some speculation that exposure to agricultural chemicals such as pesticides may impact serotonin levels in the brain and increase peoples risk for mood disorders and suicide.
Can we expect these trends to continue? Some say the answer is yes. Since elderly white males have the highest risk for suicide and there is increasing isolation of the elderly in rural America, one might be concerned about increased risk for this population. Also, the ongoing drought in many parts of rural America that is added on to the past several years of economic problems facing farmers, could continue the burden of farm stress, loss and increase the risk of rural suicide.
Resources:
Centers for Disease Control Suicide Fact Sheet Website (http://www.cdc.gov/ncipc/factsheets/
suifacts.htm)
U.S. Public Health Service, The Surgeon General's Call to Action to Prevent Suicide. Washington DC: 1999.
Kay Redfield Jamison Night Falls Fast: Understanding Suicide, New York: Alfred A. Knopf, 1999.
The Evangelical Lutheran Church in America has adopted "A Message on Suicide Prevention." Single, complimentary copies may be obtained by calling 800-638-3522, ext. 2718. This message can also be found online (www.elca.org/dcs/suicide_prevention.html)
National Organizations:
American Association of Suicidology (ASS), 4201 Connecticut Ave., NW, Suite 408, Washington, DC 20008. Phone: (202) 237-2280 E-mail: ssilive15@ixnetcom.com Website: www.suicidology.org
American Foundation for Suicide Prevention (AFSP), 120 Wall Street, 22nd Floor, New York, New York 10005. Phone (888) 333-2377 E-mail: rfabrika@asfp.org Website: www.afsp.org
National Organization for People of Color Against Suicide, P.O. Box 125, San Marcos, Texas 78667. Phone: (830) 625-3576 E-mail: db31@swt.edu
The Organization for Attempters and Survivors of Suicide in Interfaith Services (OASSIS), 4541 Burlington Place, NW, Washington, DC 20016. Phone: (202) 363-4224 E-mail: cthv45a@prodigy.com
SA\VE - Suicide Awareness \ Voices of Education, 7317 Cahill Road, Suite 207, Edina, Minnesota 55439. Phone: (612) 946-7998 E-mail: save@winternet.org Website: www.save.org
Suicide Prevention Advocacy Network USA (SPAN USA), 5034 Odins Way, Marietta, Georgia 30068. Phone (888) 649-1366 E-mail: act@spanusa.org Website: www.spanusa.org
Yellow Ribbon Suicide Prevention Program, P.O. Box 664, Westminster, Colorado 80030. Phone: (303) 426-4496 E-mail: yellowribbon@aol.com
References:
Gunderson, P.; Donner, D.; Nashold, R.; Salkowicz, L.; Sperry, S.; & Wittman, B. "The Epidemiology of Suicide Among Farm Residents or Workers in Five North-Central States, 1980-1988." Farm Injuries: A Public Health Approach. American Journal of Preventive Medicine, 9:26-32, May/June, 1993.
Hartley, D.; Bird, D.; and Dempsey, P. "Rural Mental Health and Substance Abuse," Rural Health in the United States, Thomas C. Ricketts III (Ed.), Oxford University Press, 1999.
Jamison, Kay Redfield Night Falls Fast: Understanding Suicide. New York: Alfred A. Knopf, 1999.
Kelly, S. & Charlton, J. "Suicide Deaths in England and Wales, 1982-92: The Contribution of Occupation and Geography" Population Trends, No. 80, Summer, 1995.
Morrison, H.I.; Semenciw, R.W.; Morison D.; Mao, Y. "Mortality among Canadian Fruit and Vegetable Farmers." Presentation at the Third International Symposium: Issues in Health, Safety and Agriculture; Saskatoon, Saskatchewan, Canada; 10-15 May, 1992.
National Rural Health Alliance "Youth Suicide in Rural and Remote Australia," Issues Paper No. 6, 1998.
Neal, R. "Suicide in China Gives Unexpected View on Americans Who Kill Themselves," Social Medicine, Focus (February 6), Harvard University, 1998.
Office of Technology Assessment. Health Care in Rural America (OTA Publication No. OTA-H-434). Washington, DC: US Government Printing Office, 1990.
Ortega, S.T., Johnson, D.R., Beeson, P.G., & Craft, B.J. "The Farm Crisis and Mental Health: A Longitudinal Study of the 1980s," Rural Sociology, 54(4), pp. 598-619, 1994.
Rosmann, M.R. "Farming: A Way Of Life And Death," Unpublished manuscript. Sharing Help Awareness United Network, Harlan, Iowa, 2000.
Saftlass, A.F.; Blair, A.; Cantor, R.P.; Hanrahan, L.; and Anderson, H.A. "Cancer and Other Causes of Death Among Wisconsin Farmers." American Journal of Internal Medicine, vol. 11, pp. 119-129, 1987.
Stack, S. "Suicide: A Decade Review of the Sociological Literature." Deviant Behavior, vol. 4, pp. 41-66, 1982.
Stallones, L. "Suicide Rates Among Male Farmers in Colorado, 1980-1988." Presentation at the Annual Meeting of the American Public Health Association; Atlanta; 9-13, November 1991.
Rosmann, M.R. "Farming: A Way of Life and Death," unpublished paper, 1999.
U.S. Public Health Service, The Surgeon General's Call to Action to Prevent Suicide. Washington D.C.: 1999.
Wallace, J.D.; Calhoun, A.D.; Powell, K.E.; O'Neil, J. & James, S.P. Homicide and Suicide Among Native Americans, 1979-1992 (Violence Surveillance Series, No. 2). Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 1996.
Wilkinson, K.P., & Israel, J.D. "Suicide and Rurality in Urban Society." Suicide and Life-Threatening Behavior, Vol. 14, pp. 187-199, 1984.
Zacharakis, C.A.; M.G. Madianos, G.N. Papadimitriou, and Stefanis, C.N. "Suicide in Greece 1980-1995: Patterns and Social Factors," Social Psychiatry and Psychiatric Epidemiology. Vol. 33, Issue 10 (1998) pp. 471-476.