State-level suicide mortality insights: a comparative study of VHA veterans and the whole US population

Abstract

Background: Suicide is a leading cause of death in the US Comparative State-level spatial analysis between Veterans Health Administration (VHA veterans) and the whole US population can reveal differences in conditions for targeted interventions and intricate geographical patterns.

Methods: The study population contains 2018 and 2019 suicide deaths of VHA veterans and the whole US population. They were used to calculate state-level rates. States were classified by whether their VHA veteran and whole US population rates were above or below respective mean rates. Local Moran's I was leveraged to examine spatial autocorrelation.

Results: State-level suicide mortality rates and disparities among states were generally higher for VHA veterans (2018: 37.3 ± 7.2; 2019: 46.8 ± 8.3) than for the whole US population (2018: 16.6 ± 4.3; 2019: 16.4 ± 4.4). For both populations, there were statistically significant clusters with high suicide rates. Over one-fourth of states demonstrated inverse relationships, with rates above mean for one group but below for other. VHA veterans are at higher risk with over one-third of states had greater than average veteran suicide risk ratio.

Conclusions: VHA veterans are at higher risk than the whole population across all states. Mortality disparities among states and clusters of states with high and low rates suggest targeted interventions and cooperative health strategies may help address these differences.

Keywords: US veterans; clustering; epidemiology; spatial analysis; suicide.

Figure 1

State-level distributions of suicide mortality for US VHA veterans and the whole population from 2018 to 2019. Maps of suicide rates along with clusters from local Moran’s I for US VHA veterans in 2018 (a) and 2019 (b) and the whole US population in 2018 (c) and 2019 (d). High-high and low-low indicate clusters of high and low suicide rates, respectively. High-low and low-high identify outlier states with high rates surrounded by states with low rates and with low rates surrounded by states with high rates, respectively. Categorical maps of suicide mortality greater than the mean suicide rates for VHA veterans and the whole US population combined in 2018 (e) and 2019 (f). For each year, mean rates were calculated separately for the two populations. Based on these mean rates, we divided all states into four categories that include higher than mean rate for both populations (green), higher than mean for the whole population only (yellow), higher than mean for VHA veterans only (pink), and lower than mean rate for both populations (gray). States with suicide mortality rates higher than the third quartile are marked with a star.

Figure 2

State-level relative risk for VHA suicide in contrast to the whole population within US States for 2018 and 2019 (c). The blue and orange lines represent mean VHA veteran suicide risk ratio for 2018 and 2019.