title: Suicide among patients in the Veterans Affairs health system: rural-urban differences in rates, risks, and methods.
abstract: OBJECTIVE
  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.
authors.affiliation: Department of Veterans Affairs, Office of Mental Health Operations, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Ann Arbor, MI 48109, USA. John.McCarthy2@VA.gov
authors.forename: John F
authors.initials: JF
authors.lastname: McCarthy
authors.forename: Frederic C
authors.initials: FC
authors.lastname: Blow
authors.forename: Rosalinda V
authors.initials: RV
authors.lastname: Ignacio
authors.forename: Mark A
authors.initials: MA
authors.lastname: Ilgen
authors.forename: Karen L
authors.initials: KL
authors.lastname: Austin
authors.forename: Marcia
authors.initials: M
authors.lastname: Valenstein
mesh_terms: D016009:Chi-Square Distribution; D005260:Female; D006801:Humans; D008297:Male; D016016:Proportional Hazards Models; D012307:Risk Factors; D012424:Rural Population / Q000706:statistics & numerical data*; D018709:Statistics, Nonparametric; D013405:Suicide / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology; D014505:Urban Population / Q000706:statistics & numerical data*; D014728:Veterans / Q000523:psychology / Q000706:statistics & numerical data*