Sep. 21, 2009 There is a strong relationship between drinking and taking one's own life. In any given year, people with alcohol dependence (AD) commit more than 20 percent of suicides in the general population; some 80 to 90 percent of AD suicides are by men, mostly white. A new look at suicide and alcohol has found that both attempted and completed suicides occur at greater rates in rural communities with greater bar densities.
"Our study is unique in that it is spatial, longitudinal, and examines the relationship between suicide and features of the environment such as alcohol outlets, particularly bars, that might not at first glance appear related to suicide," explained Fred W. Johnson, associate research scientist at the Prevention Research Center and corresponding author for the study. "The question we sought to answer was: 'Is increased alcohol-outlet density associated with increased rates of completed suicide and of suicide attempts?'"
Johnson and his colleagues examined data – including population characteristics such as age, and place characteristics such as number of alcohol outlets – from 581 zip-code areas in California from 1995 to 2000. They also obtained numbers of hospitalizations for injuries caused by suicide attempts.
"When using aggregate data in a study like ours, one must take great care interpreting the results," cautioned Johnson. "Because it is difficult or perhaps impossible to obtain data from patrons who first drink at a bar and later take their own lives, the best one can do is refer to the results of aggregate studies like this one. Although one cannot make the strong statement that more bars cause more suicides, our findings are at least consistent with what we would expect if patronizing bars or other alcohol outlets were in fact causally related to suicide."
The results showed that completed suicides were more common in less populous zip-code areas, such as rural communities, and in zip-code areas with larger proportions of older, lower-income whites, but less common in zip code areas with larger proportions of blacks and Hispanics. Suicide attempts were also more common in rural zip codes, but those who attempted suicide were younger, and included blacks and Hispanics as well as whites.
"This suggests that the suicide rate is higher in rural areas," said Johnson. "The absolute count of suicides may be higher in urban areas because of their much greater population compared to rural areas, but the rate of suicides, the number of suicides per population, is greater in rural areas."
These results could be due to some contextual effect that affects both drinkers and non-drinkers, commented Dennis M. Gorman, interim director of the Health Science Center at Texas A&M University.
"For example, rural places with lots of bars might be depressing places to live in due to isolation, lack of social ties, etc.," said Gorman. "This 'depressing' context would affect all who live there, both drinkers and non-drinkers. The authors seem to suggest such a contextual protective effect when explaining the negative correlation between restaurants and suicides; that [restaurants] are located in areas in which suicides typically do not occur. In this case, it is not the restaurant per se that has a protective effect, but the context or area in which these are located that matters."
Johnson agreed. "Other factors include population loss as youth desert rural towns to find jobs and opportunity in urban areas," he said. "The average age of farmers is now rising toward 60, an age when suicide rates increase as medical problems multiply and social isolation increases. Some small towns cannot attract industry and jobs with tax and other incentives, meanwhile property values plummet. More frequent possession of firearms in rural areas is a major factor in rural suicides, with 75 percent of rural completed suicides nationally and 57 percent of rural completed suicides in California involving firearms."
Both Johnson and Gorman said these findings highlight a growing problem in rural American.
"Most alcohol problems are not caused by the alcohol dependent, but by ordinary people who drink too much on a given occasion, leading to motor vehicle, pedestrian, and bicycle accidents," said Johnson. "All of these problems are related to alcohol outlets, as are more sinister problems such as homicide, assault, domestic violence, child abuse, and child neglect. This study suggests that suicide may be one of the more severe problems related to alcohol outlets, and further suggests that one way to reduce suicides and other problems related to alcohol outlets is to reduce the number of outlets, particularly bars."
"One might also advise against moving into areas that have a high density of bars and off-premise alcohol outlets," said Gorman. "There are a number of social problems that seem to cluster in places with high alcohol-outlet density, excluding restaurants, whether this is as a result of alcohol consumption or a result of problem-prone individuals being attracted into such areas."
"It is unfortunate that the rural-suicide problem, along with other rural problems, are unlikely to get the attention they deserve because ours is such a predominantly urban society and there are so many pressing urban problems affecting great numbers of people and that the media can highlight given its proximity to these urban problems," said Johnson. "This is ironic, given a recent New York Times article that called for abandoning corporate farms and returning to independent farms like the one the author grew up on in Oregon. This would be healthier for all of us and might reduce the rural suicide rate to what it was early in the last century, when it was lower than the urban rate, and when rural America, rather than desolate and lonely, was thriving and vibrant, perhaps as idyllic as it was in fable."
The study was funded by the National Institute on Alcohol Abuse and Alcoholism.
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- Fred W. Johnson, Paul J. Gruenewald and Lillian G. Remer. Suicide and Alcohol: Do Outlets Play a Role? Alcoholism: Clinical & Experimental Research, December, 2009
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