INTRODUCTION Suicide rates in the United States have risen nearly 30% since 1999, and mental health conditions are one of several factors contributing to suicide. Examining state-level trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning. METHODS Trends in age-adjusted suicide rates among persons aged ≥10 years, by state and sex, across six consecutive 3-year periods (1999-2016), were assessed using data from the National Vital Statistics System for 50 states and the District of Columbia. Data from the National Violent Death Reporting System, covering 27 states in 2015, were used to examine contributing circumstances among decedents with and without known mental health conditions. RESULTS During 1999-2016, suicide rates increased significantly in 44 states, with 25 states experiencing increases >30%. Rates increased significantly among males and females in 34 and 43 states, respectively. Fifty-four percent of decedents in 27 states in 2015 did not have a known mental health condition. Among decedents with available information, several circumstances were significantly more likely among those without known mental health conditions than among those with mental health conditions, including relationship problems/loss (45.1% versus 39.6%), life stressors (50.5% versus 47.2%), and recent/impending crises (32.9% versus 26.0%), but these circumstances were common across groups. CONCLUSIONS Suicide rates increased significantly across most states during 1999-2016. Various circumstances contributed to suicides among persons with and without known mental health conditions. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE States can use a comprehensive evidence-based public health approach to prevent suicide risk before it occurs, identify and support persons at risk, prevent reattempts, and help friends and family members in the aftermath of a suicide.

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Vital Signs: Trends in State Suicide Rates - United States, 1999-2016 and Circumstances Contributing to Suicide - 27 States, 2015.

Importance Differences in obesity by sex, age group, race and Hispanic origin among US adults have been reported, but differences by urbanization level have been less studied. Objectives To provide estimates of obesity by demographic characteristics and urbanization level and to examine trends in obesity prevalence by urbanization level. Design, Setting, and Participants Serial cross-sectional analysis of measured height and weight among adults aged 20 years or older in the 2001-2016 National Health and Nutrition Examination Survey, a nationally representative survey of the civilian, noninstitutionalized US population. Exposures Sex, age group, race and Hispanic origin, education level, smoking status, and urbanization level as assessed by metropolitan statistical areas (MSAs; large: ≥1 million population). Main Outcomes and Measures Prevalence of obesity (body mass index [BMI] ≥30) and severe obesity (BMI ≥40) by subgroups in 2013-2016 and trends by urbanization level between 2001-2004 and 2013-2016. Results Complete data on weight, height, and urbanization level were available for 10 792 adults (mean age, 48 years; 51% female [weighted]). During 2013-2016, 38.9% (95% CI, 37.0% to 40.7%) of US adults had obesity and 7.6% (95% CI, 6.8% to 8.6%) had severe obesity. Men living in medium or small MSAs had a higher age-adjusted prevalence of obesity compared with men living in large MSAs (42.4% vs 31.8%, respectively; adjusted difference, 9.8 percentage points [95% CI, 5.1 to 14.5 percentage points]); however, the age-adjusted prevalence among men living in non-MSAs was not significantly different compared with men living in large MSAs (38.9% vs 31.8%, respectively; adjusted difference, 4.8 percentage points [95% CI, −2.9 to 12.6 percentage points]). The age-adjusted prevalence of obesity was higher among women living in medium or small MSAs compared with women living in large MSAs (42.5% vs 38.1%, respectively; adjusted difference, 4.3 percentage points [95% CI, 0.2 to 8.5 percentage points]) and among women living in non-MSAs compared with women living in large MSAs (47.2% vs 38.1%, respectively; adjusted difference, 4.7 percentage points [95% CI, 0.2 to 9.3 percentage points]). Similar patterns were seen for severe obesity except that the difference between men living in large MSAs compared with non-MSAs was significant. The age-adjusted prevalence of obesity and severe obesity also varied significantly by age group, race and Hispanic origin, and education level, and these patterns of variation were often different by sex. Between 2001-2004 and 2013-2016, the age-adjusted prevalence of obesity and severe obesity significantly increased among all adults at all urbanization levels. Conclusions and Relevance In this nationally representative survey of adults in the United States, the age-adjusted prevalence of obesity and severe obesity in 2013-2016 varied by level of urbanization, with significantly greater prevalence of obesity and severe obesity among adults living in nonmetropolitan statistical areas compared with adults living in large metropolitan statistical areas.

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Differences in Obesity Prevalence by Demographic Characteristics and Urbanization Level Among Adults in the United States, 2013-2016.

Understanding and addressing the unique health needs of people residing in rural America is critical to the American Heart Association's pursuit of a world with longer, healthier lives. Improving the health of rural populations is consistent with the American Heart Association's commitment to health equity and its focus on social determinants of health to reduce and ideally to eliminate health disparities. This presidential advisory serves as a call to action for the American Heart Association and other stakeholders to make rural populations a priority in programming, research, and policy. This advisory first summarizes existing data on rural populations, communities, and health outcomes; explores 3 major groups of factors underlying urban-rural disparities in health outcomes, including individual factors, social determinants of health, and health delivery system factors; and then proposes a set of solutions spanning health system innovation, policy, and research aimed at improving rural health.

Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association.

Background The suicide case-fatality rate (CFR)-the proportion of suicidal acts that are fatal-depends on the distribution of methods used in suicidal acts and the probability of death given a particular method (method-specific CFR). Objective To estimate overall and method-specific suicide CFRs and the distribution of methods used in suicidal acts by demographic characteristics. Design Cross-sectional study. Setting United States, 2007 to 2014. Participants Suicide deaths (n = 309 377 records from the National Vital Statistics System) and nonfatal suicide attempts requiring treatment in an emergency department (ED) (n = 1 791 638 records from the Nationwide Emergency Department Sample) or hospitalization (n = 1 556 871 records from the National [Nationwide] Inpatient Sample) among persons aged 5 years or older. Measurements Rates of suicide deaths and nonfatal suicide attempts, overall and method-specific CFRs, and distribution of methods used, by sex, age group, region, and urbanization. Results Overall, 8.5% of suicidal acts were fatal (14.7% for males vs. 3.3% for females; 3.4% for persons aged 15 to 24 years vs. 35.4% for those aged ≥65 years). Drug poisoning accounted for 59.4% of acts but only 13.5% of deaths; firearms and hanging accounted for only 8.8% of acts but 75.3% of deaths. Firearms were the most lethal method (89.6% of suicidal acts with a firearm resulted in death), followed by drowning (56.4%) and hanging (52.7%). Method-specific CFRs were higher for males and older persons. The distribution of methods varied across demographic groups. Limitations Results are based on suicidal acts resulting in an ED visit, a hospitalization, or death. Consequently, the reported CFRs are larger than they would have been had the data included nonfatal attempts that did not result in an ED visit. Conclusion Variation in overall suicide CFR between sexes and across age groups, regions, and urbanization is largely explained by the distribution of methods used in suicidal acts. Primary funding source Joyce Foundation.

Suicide Case-Fatality Rates in the United States, 2007 to 2014: A Nationwide Population-Based Study

Given the recent rise in adolescent mental health issues, many researchers have turned to school-based mental health programs as a way to reduce stress, anxiety, and depressive symptoms among large groups of adolescents. The purpose of the current systematic review and meta-analysis is to identify and evaluate the efficacy of school-based programming aimed at reducing internalizing mental health problems of adolescents. A total of 42 articles, including a total of 7310 adolescents, ages 11-18, met inclusion for the meta-analyses. Meta-analyses were completed for each of the three mental health outcomes (stress, depression, and anxiety) and meta-regression was used to determine the influence of type of program, program dose, sex, race, and age on program effectiveness. Overall, stress interventions did not reduce stress symptoms, although targeted interventions showed greater reductions in stress than universal programs. Overall, anxiety interventions significantly reduced anxiety symptoms, however higher doses may be necessary for universal programs. Lastly, depression interventions significantly reduced depressive symptoms, but this reduction was moderated by a combination of program type, dose, race, and age group. Although, school-based programs aimed at decreasing anxiety and depression were effective, these effects are not long-lasting. Interventions aimed at reducing stress were not effective, however very few programs targeted or included stress as an outcome variable. Implications for practice, policy and research are discussed.

A Systematic Review and Meta-Analysis of School-Based Stress, Anxiety, and Depression Prevention Programs for Adolescents

PROBLEM/CONDITION Suicide is a public health problem and one of the top 10 leading causes of death in the United States. Substantial geographic variations in suicide rates exist, with suicides in rural areas occurring at much higher rates than those occurring in more urban areas. Understanding demographic trends and mechanisms of death among and within urbanization levels is important to developing and targeting future prevention efforts. REPORTING PERIOD 2001-2015. DESCRIPTION OF SYSTEM Mortality data from the National Vital Statistics System (NVSS) include demographic, geographic, and cause of death information derived from death certificates filed in the 50 states and the District of Columbia. NVSS was used to identify suicide deaths, defined by International Classification of Diseases, 10th Revision (ICD-10) underlying cause of death codes X60-X84, Y87.0, and U03. This report examines annual county level trends in suicide rates during 2001-2015 among and within urbanization levels by select demographics and mechanisms of death. Counties were collapsed into three urbanization levels using the 2006 National Center for Health Statistics classification scheme. RESULTS Suicide rates increased across the three urbanization levels, with higher rates in nonmetropolitan/rural counties than in medium/small or large metropolitan counties. Each urbanization level experienced substantial annual rate changes at different times during the study period. Across urbanization levels, suicide rates were consistently highest for men and non-Hispanic American Indian/Alaska Natives compared with rates for women and other racial/ethnic groups; however, rates were highest for non-Hispanic whites in more metropolitan counties. Trends indicate that suicide rates for non-Hispanic blacks were lowest in nonmetropolitan/rural counties and highest in more urban counties. Increases in suicide rates occurred for all age groups across urbanization levels, with the highest rates for persons aged 35-64 years. For mechanism of death, greater increases in rates of suicide by firearms and hanging/suffocation occurred across all urbanization levels; rates of suicide by firearms in nonmetropolitan/rural counties were almost two times that of rates in larger metropolitan counties. INTERPRETATION Suicide rates in nonmetropolitan/rural counties are consistently higher than suicide rates in metropolitan counties. These trends also are observed by sex, race/ethnicity, age group, and mechanism of death. PUBLIC HEALTH ACTION Interventions to prevent suicides should be ongoing, particularly in rural areas. Comprehensive suicide prevention efforts might include leveraging protective factors and providing innovative prevention strategies that increase access to health care and mental health care in rural communities. In addition, distribution of socioeconomic factors varies in different communities and needs to be better understood in the context of suicide prevention.

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Marcie-Jo Kresnow-Sedacca

Papers

Suicide Trends Among and Within Urbanization Levels by Sex, Race/Ethnicity, Age Group, and Mechanism of Death - United States, 2001-2015.