title: Suicide rates in relation to health care access in the United States: an ecological study.
abstract: OBJECTIVE
  We tested the hypothesis that suicide rates in the United States are associated with indicators of access to health care services.
  
  
  METHODS
  With an ecological study design, we compared age-adjusted suicide rates for men and women with demographic, socioeconomic, and other indices of access to health care, by state (N = 51, including the District of Columbia). The most recently available information from the National Statistics Reports at the U.S. Census Bureau, the U.S. Centers for Disease Control and Prevention National Center for Health Statistics, and the American Board of Medical Specialties was used. Data on suicide are from 2001; other measures were matched for the closest available year, except that state-based data on psychiatrists and physicians are from 2004.
  
  
  RESULTS
  Positive bivariate associations with state suicide rates (all p < or = .005) are ranked as follows: male sex, Native American ethnicity, and higher proportion of uninsured residents. Negative bivariate associations (all p < or = .002) are ranked as follows: higher population density, higher annual per capita income, higher population density of psychiatrists, higher population density of physicians, higher federal aid for mental health, and higher proportion of African Americans. All factors were associated with state suicide rates in expected directions. In multivariate models of associations between suicide rates and indices of access to health care, the state rate of federal aid for mental health was the strongest indicator, followed by the rate of uninsured persons and population density of psychiatrists and physicians and by population density.
  
  
  CONCLUSIONS
  Such aggregate analyses cannot specify risk indices for individual persons. Nevertheless, the methods employed detected several factors with well-established associations with suicide. They also yielded strong correlations of state-based suicide rates with proposed indicators of access to health care. The findings support the view that clinical intervention is a crucial element in the prevention of suicide.
authors: Department of Psychiatry and Neuroscience Program, Harvard Medical School, Boston, MA, USA. ltondo@mclean.harvard.edu
authors: Leonardo
authors: L
authors: Tondo
authors: Matthew J
authors: MJ
authors: Albert
authors: Ross J
authors: RJ
authors: Baldessarini