The geography of self-injury: Spatial patterns in attempted and completed suicide
Introduction
While suicide rates in New Jersey are among the lowest in the nation, suicide remains a significant cause of preventable mortality. Between 1999–2001 there were approximately 1770 suicides in the state. Furthermore, suicide follows a pronounced spatial pattern in New Jersey, in which rates are generally higher in the more rural counties, principally those located in the South and northwest of the state (Hempstead, 2002). This spatial pattern is strongest among white males, and mirrors a national geographic pattern in which suicide rates are highest in states with relatively low population density such as Wyoming and Alaska (Frankel & Taylor, 1992; Saunderson, Haynes, & Langford, 1998; Wilkinson & Israel, 1984; Zekeri & Wilkinson, 1995). Nationally, the age and geographical pattern of suicide among African–Americans is quite different, as rates for this population seem to be lower in rural areas (Willis, Coombs, Drentea, & Cockerham, 2003). The overall rural–urban suicide differential in English-speaking countries is well known and has been increasing in recent years (Singh & Siahpush, 2002). Far less is known about the spatial pattern of non-fatal self injury. Between 1999 and 2001, there were more than 12,000 non-fatal suicide acts in New Jersey which resulted in hospitalization. While New Jersey's suicide rates are low relative to those of the rest of the nation, rates of inpatient hospitalization for non-fatal self-injury are similar to the national average. As compared with completed suicides, those attempting suicide are more likely to be young, female and non-white.
Not all completed suicides are preceded by a suicide attempt, and the majority of attempters do not go on to commit suicide, as evidenced by the huge imbalance in annual numbers of fatal and non-fatal self-injury (National Institute of Mental Health (NIMH), 2004). In New Jersey, preliminary unpublished data from the 2003 National Violent Death Reporting System suggests that in 21% of completed suicides, there was a report of a prior attempt (Center for Health Statistics (CHS), 2005). Thus, the relationship between fatal and non-fatal self-injury is complex, and within the category of non-fatal self-injury there is much variation in seriousness of intent. The population of suicide attempters consists of relatively mild attempts, which are distinguishable from more severe attempts by use of less lethal methods such as wrist cutting and ingestion of medicines, as opposed to leaps from high places, suffocation and ingestion of toxic chemicals. Mild attempts are more common among females and adolescents and often result in negligible physical injuries. Since individuals who make mild attempts share few characteristics with completed suicides it has been argued that it may be more appropriate to refer to them as “parasuicide” rather than “attempted suicide”, the latter term which might be reserved for more serious attempts (Arensman & Kerkhof, 1996). While such a classification may be made in future analyses, for the present purposes suicidal behavior will be simply categorized into fatal and non-fatal groups.
Section snippets
Background
Research on suicidal behavior tends to focus either on demographic and social risk factors or underlying psychological processes. Mental illness, particularly depression, is widely acknowledged to be the single most important individual risk factor for suicide. In addition to depression, there are many other individual factors that appear to be significant, such as substance abuse, chronic pain, terminal illness or disability, domestic violence or a history of child abuse. Additionally,
Data and methods
Information on suicides comes from New Jersey death certificates and the multiple cause of death files, with some supplemental information obtained from medical examiner reports. Suicide is under-reported in all states, with some suicides misreported as unintentional or undetermined. This is particularly true for poisoning deaths. The extent of this under-reporting varies by state, and is not known for New Jersey. However, the proportion of poisoning deaths which are coded as undetermined is
Self-injury in New Jersey
As can be seen in Fig. 1, suicide rates are considerably lower in New Jersey than elsewhere although, in recent years, the gap has narrowed somewhat, primarily due to greater reduction in suicide rates in the rest of the nation. In 2001, rates rose slightly both in New Jersey as well as for the nation as a whole. Fig. 2 shows age-adjusted suicide rates by major mechanism. As can be seen, the major source of the difference in suicide rates between New Jersey and the nation as a whole is in the
Discussion
This study examined demographic and spatial characteristics of fatal and non-fatal suicidal behavior in New Jersey. There were two major objectives. One was to determine whether a rural–urban difference in suicide rates could be observed within a densely populated state such as New Jersey. Another goal was to see whether fatal and non-fatal self-injury had similar geographical distributions. With regard to the first objective, results suggest that even within a highly urbanized state such as
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