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.
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