Achieving health equity in US suicides: a narrative review and commentary

(2022) 22:1360 Perry et al. BMC Public Health https://doi.org/10.1186/s12889-022-13596-w Open Access REVIEW Achieving health equity in US suicides: a narrative review and commentary Seth W. Perry1,2,3,4*†, Jacob C. Rainey5, Stephen Allison6, Tarun Bastiampillai6,7,8, Ma‑Li Wong1,2,6, Julio Licinio1,2,6,9,10, Steven S. Sharfstein11,12 and Holly C. Wilcox5,13† Abstract Suicide rates in the United States (US) reached a peak in 2018 and declined in 2019 and 2020, with substantial and often growing disparities by age, sex, race/ethnicity, geography, veteran status, sexual minority status, socioeconomic status, and method employed (means disparity). In this narrative review and commentary, we highlight these many disparities in US suicide deaths, then examine the possible causes and potential solutions, with the overarching goal of reducing suicide death disparities to achieve health equity. The data implicate untreated, undertreated, or unidentified depression or other mental illness, and access to firearms, as two modifiable risk factors for suicide across all groups. The data also reveal firearm suicides increasing sharply and linearly with increasing county rurality, while suicide rates by falls (e.g., from tall structures) decrease linearly by increasing rurality, and suicide rates by other means remain fairly constant regardless of relative county urbaniza‑ tion. In addition, for all geographies, gun suicides are significantly higher in males than females, and highest in ages 51–85 + years old for both sexes. Of all US suicides from 1999–2019, 55% of male suicides and 29% of female suicides were by gun in metropolitan (metro) areas, versus 65% (Male) and 42% (Female) suicides by gun in non-metro areas. Guns accounted for 89% of suicides in non-metro males aged 71–85 + years old. Guns (i.e., employment of more lethal means) are also thought to be a major reason why males have, on average, 2–4 times higher suicide rates than women, despite having only 1/4—1/2 as many suicide attempts as women. Overall the literature and data strongly implicate firearm access as a risk factor for suicide across all populations, and even more so for male, rural, and older populations. To achieve the most significant results in suicide prevention across all groups, we need 1) more emphasis on policies and universal programs to reduce suicidal behaviors, and 2) enhanced population-based strategies for ameliorating the two most prominent modifiable targets for suicide prevention: depression and firearms. Keywords: Suicide, Health equity, Health disparities, Depression, Guns, Firearms, Lethal means, Rural, Urban, Geography, Disparity, Public health † Seth W. Perry and Holly C. Wilcox shared senior authorship. *Correspondence: 1 Department of Psychiatry and Behavioral Sciences, College of Medicine, State University of New York (SUNY, Upstate Medical University, Syracuse, NY, USA Full list of author information is available at the end of the article Background Data suggests that the existence of more evidence-based mental health treatments has not significantly reduced depression prevalence and suicide in the US, and that significant personal (i.e., stigma) or practical/logistical barriers to effective mental health care remain [1]. Depression and suicide rates have risen significantly over this same time period, with health disparities identified in both depression and suicide based on age, sex, race/ © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Perry et al. BMC Public Health (2022) 22:1360 ethnicity, geography, veteran status, sexual minority status, and/or socioeconomic status [2]. Combating these distressing trends to achieve health equity will require greater attention to proactive, evidence-based, sustainable, and practical solutions that address the varied causes, sociodemographics, mechanisms, and differential risk factors of suicide deaths. However, to make progress in these areas, first we must understand precisely and granularly 1) What are the disparities that exist in suicide deaths, and 2) What are the key forces that drive suicides and suicide disparities? In addition, gaining better understanding of the varied (e.g., biologic, sociodemographic, or perhaps even genetic or epigenetic) factors that may promote lower suicide deaths in some populations has great potential to help guide improved prevention strategies for higher-risk populations. To achieve these goals, this paper will explore sociodemographic disparities that exist in suicide deaths, with emphasis on two of the most significant modifiable targets for suicide prevention: 1) untreated or undertreated depression, and 2) access to the lethal means (firearms) that cause more suicide deaths than all other means combined and thus pose the greatest threat to individual and public health. Furthermore, herein we newly define increased or unsafe (i.e., disparate) access to firearms as a suicide health disparity that promotes health inequities. Finally, we discuss strategies for improving health equity surrounding suicide deaths in each of the areas discussed. Overall, the data suggest that more effective prevention, early identification, and treatment of depression and other mental health disorders that carry suicide risk (e.g., bipolar disorder, schizophrenia), as well as strategically and effectively employed firearm safety measures, would help reduce suicide deaths and improve health equity. Readers should note that this is not a systematic review, and therefore should not be interpreted as such. Rather, this paper is part narrative review and part commentary, with accompanying presentation of publicly available suicide data to help illustrate our points. By design, this manuscript does not fit neatly into any of the usual boxes, with the intention of providing a unique contribution to the suicide literature. To our knowledge, few previous papers have discussed the health equity aspects of su (...truncated)