Suicide among patients in the Veterans Affairs health system: Rural – urban differences in rates, risks and methods

Objectives: Suicide among Veterans is a national concern. The Veterans Affairs (VA) health system is the largest integrated health system in the United States. The VA serves a population that is disproportionately and increasingly rural, and suicide may be more frequent in rural patients. Using national patient cohorts, we assessed rural-urban differences in suicide rates, risks, and methods. Methods: We identified all VA patients in fiscal years 2003-2004 (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=5,722,829). Mortality (FY04-05, FY07-08) was assessed from National Death Index searches. Census criteria defined rurality. Proportional hazards regressions calculated rural-urban differences in risks, controlling for age, sex, 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 greater suicide rates (38.8 vs. 31.4/100,000 person-years in FY04-05; 39.6 vs. 32.3/100,000 in FY07-08). In multivariable analyses, rural residence was associated with greater suicide risks (20% greater, FY04-05; 22% greater, FY07-08). Firearm deaths were more common in rural suicides (76.6% vs. 61.5% in FY07-08). Conclusions: Rural residence is a substantial suicide risk factor, even controlling for mental health accessibility. Suicide prevention, gun safety, and treatment enhancements should specifically address risks in rural patients.