FIGURE 2-4 Suicide Rates by Urbanization and Use of Firearms Among Persons 15–64 Years: United States, 1996–1998. Source: NCHS (2001). Provided by LA Fingerhut.

Limited access to mental health services and to emergency care have been implicated in the increased rates seen in some rural areas. Rural residents suffer higher overall mortality rates from accidents and injuries of all intents because of isolation from care facilities (IOM, 1999). Mental health services are poor in many rural areas (e.g., Howland, 1995) and travel distance to mental health treatment impedes use by rural residents (Fortney et al., 1999, see also Chapter 9).

The reported suicide rates are confounded by the effects of race, sex, and age. A statistical analysis described in Appendix A illustrates an approach to adjust rates for these variables. That analysis reveals that even after accounting for these important demographic variables, considerable spatial variability remains. Again, the highest adjusted rates are typically found in the less densely populated areas of the western United States. The analysis also reveals that there are spatial anomolies; in the western United States and Alaska, where suicide rates are typically high, there are a few counties that have calculated estimates that are consistent with the national average. Similarly, in the central United States, where

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