Association of Youth Suicides and County-Level Mental Health Professional Shortage Areas in the US

Abstract

Importance: Suicide is the second leading cause of death among US adolescents. Workforce shortages of mental health professionals in the US are widespread, but the association between mental health workforce shortages and youth suicides is not well understood.

Objective: To assess the association between youth suicide rates and mental health professional workforce shortages at the county level, adjusting for county demographic and socioeconomic characteristics.

Design, setting, and participants: This retrospective cross-sectional study included all US counties and used data of all US youlth suicides from January 2015, through December 31, 2016. Data were analyzed from July 1, 2021, through December 20, 2021.

Exposures: County health-professional shortage area designation for mental health, assigned by the US Health Resources and Services Administration based on mental health professionals relative to the population, level of need for mental health services, and service availability in contiguous areas. Designated shortage areas receive a score from 0 to 25, with higher scores indicating greater workforce shortages.

Main outcomes and measures: Suicides by youth aged 5 to 19 years from 2015 to 2016 were identified from the US Centers for Disease Control and Prevention's Compressed Mortality File. A multivariable negative binomial regression model was used to analyze the association between youth suicide rates and mental health workforce shortage designation, adjusting for the presence of a children's mental health hospital and county-level markers of health insurance coverage, education, unemployment, income, poverty, urbanicity, racial and ethnic composition, and year. Similar models were performed for the subgroups of (1) firearm suicides and (2) counties assigned a numeric shortage score.

Results: During the study period, there were 5034 youth suicides (72.8% male and 68.2% non-Hispanic White) with an annual suicide rate of 3.99 per 100 000 youths. Of 3133 US counties, 2117 (67.6%) were designated as mental health workforce shortage areas. After adjusting for county characteristics, mental health workforce shortage designation was associated with an increased youth suicide rate (adjusted incidence rate ratio [aIRR], 1.16; 95% CI, 1.07-1.26) and an increased youth firearm suicide rate (aIRR, 1.27; 95% CI, 1.13-1.42). For counties with an assigned numeric workforce shortage score, the adjusted youth suicide rate increased 4% for every 1-point increase in the score (aIRR, 1.04; 95% CI, 1.02-1.06).

Conclusions and relevance: In this cross-sectional study, US county mental health professional workforce shortages were associated with increased youth suicide rates. These findings may inform suicide prevention efforts.

Figure 1.. US County Maps of the Annual Youth Suicide Rate and Health Professional Shortage Areas (HPSAs) for Mental Health, 2015 to 2016

A, County-level annual suicide rate per 100 000 youth 5 to 19 years old from 2015 to 2016. Color gradation cut points represent the 50th, 75th, 90th, 95th, and 99th percentile of the distribution of annual youth suicide rates by county. B, County HPSA designation for mental health. C, Mean county HPSA score for mental health from 2015 to 2016. HPSA scores range from 0 to 25; higher scores indicate higher degrees of mental health professional workforce shortages. Color gradation cut points represent score quartiles among counties assigned an HPSA score.

Figure 2.. Annual Youth Suicide Rate by County Health Professional Shortage Area (HPSA) Score for Mental Health, 2015 to 2016

Aggregate annual youth suicide rates were calculated by determining the annual number of youth suicides among counties with a specific mental health HPSA score and dividing by the youth population in counties with that HPSA score.