{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,13]],"date-time":"2026-03-13T19:50:08Z","timestamp":1773431408495,"version":"3.50.1"},"reference-count":36,"publisher":"BMJ","issue":"2","funder":[{"DOI":"10.13039\/100005217","name":"National Center for Injury Prevention and Control","doi-asserted-by":"publisher","award":["R49CE003095"],"award-info":[{"award-number":["R49CE003095"]}],"id":[{"id":"10.13039\/100005217","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Inj Prev"],"accepted":{"date-parts":[[2025,1,31]]},"published-print":{"date-parts":[[2025,4]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To evaluate differences in mental health and substance use circumstances by rurality and military affiliations among suicide decedents.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Multiyear (2009\u20132019) cross-sectional study of adult suicide decedents reported to the National Violent Death Reporting System. We classified suicide decedents into a four-level variable by geography (urban\/rural) and military status and evaluated the prevalence of current and past alcohol and substance use problems, mental health problem recognition and mental illness treatment. We estimated prevalence ratios using multiple imputation chain equations to account for missing data and log-binomial regression models and present stratified estimates by military and rural classification.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Findings<\/jats:title>\n                    <jats:p>There was no significant relationship between rural-military classification and alcohol use problem. Compared with urban civilians, other groups had a lower risk identified of having a substance use problem: urban military (adjusted prevalence ratio (aPR): 0.65; 95% CI: 0.60 to 0.71), rural military (aPR: 0.57; 95% CI: 0.50 to 0.66) and rural civilians (aPR: 0.95; 95% CI: 0.90 to 1.00). Recognition of a mental health problem was lower among both rural military (aPR: 0.88; 95% CI: 0.81 to 0.96) and rural civilians (aPR: 0.89; 95% CI: 0.86 to 0.92). The likelihood of current mental treatment was lower in other groups (urban military (aPR: 0.93; 95% CI: 0.89 to 0.96); rural military (aPR: 0.87; 95% CI: 0.81 to 0.94); and rural civilian (aPR: 0.89; 95% CI: 0.85 to 0.92)). There was no evidence of effect modification by military and rural classification for any outcome.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Mental health outcomes by military affiliation and urbanicity\/rurality may need to be independently assessed as social determinants of health.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/ip-2024-045430","type":"journal-article","created":{"date-parts":[[2025,2,26]],"date-time":"2025-02-26T13:20:39Z","timestamp":1740576039000},"page":"121-127","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":3,"title":["Examining contextual differences in suicide by rural\u2013urban designation and military status, 2009\u20132019: a cross-sectional analysis of the National Violent Death Reporting System"],"prefix":"10.1136","volume":"31","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6419-3433","authenticated-orcid":false,"given":"J Priyanka","family":"Vakkalanka","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine, University of Iowa, Iowa City, Iowa, USA"},{"name":"Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Eliezer","family":"Santos Leon","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Iowa, Iowa City, Iowa, USA"},{"name":"Department of Biostatistics, University of Iowa, Iowa City, Iowa, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jon","family":"Davis","sequence":"additional","affiliation":[{"name":"University of Iowa Injury Prevention Research Center, Iowa City, Iowa, USA"},{"name":"Occupational and Environmental Health, University of Iowa, Iowa City, Iowa, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Cameron","family":"Williams","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Iowa, Iowa City, Iowa, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Carri","family":"Casteel","sequence":"additional","affiliation":[{"name":"University of Iowa Injury Prevention Research Center, Iowa City, Iowa, USA"},{"name":"Occupational and Environmental Health, University of Iowa, Iowa City, Iowa, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,2,26]]},"reference":[{"key":"2026031307301159000_31.2.121.1","unstructured":"Centers for Disease Control and Prevention . Facts about Suicide, 2023. Available: https:\/\/www.cdc.gov\/suicide\/facts\/index.html"},{"key":"2026031307301159000_31.2.121.2","doi-asserted-by":"publisher","DOI":"10.15585\/mmwr.mm6903a1"},{"key":"2026031307301159000_31.2.121.3","unstructured":"Centers for Disease Control and Prevention . Suicide in Rural America, 2023. Available: https:\/\/www.cdc.gov\/ruralhealth\/Suicide.html"},{"key":"2026031307301159000_31.2.121.4","doi-asserted-by":"publisher","DOI":"10.15585\/mmwr.mm6610a2"},{"key":"2026031307301159000_31.2.121.5","doi-asserted-by":"crossref","DOI":"10.1016\/j.ssmph.2021.100847","article-title":"Barriers to healthcare access among U.S. adults with mental health challenges: A population-based study","volume":"15","author":"Coombs","year":"2021","journal-title":"SSM Popul Health"},{"key":"2026031307301159000_31.2.121.6","unstructured":"Rural Health Information Hub . Barriers to Mental Health Treatment in Rural Areas, Available: https:\/\/www.ruralhealthinfo.org\/toolkits\/mental-health\/1\/barriers"},{"key":"2026031307301159000_31.2.121.7","doi-asserted-by":"crossref","DOI":"10.1186\/s12913-020-4956-6","article-title":"Potentially avoidable inter-facility transfer from Veterans Health Administration emergency departments: A cohort study","volume":"20","author":"Mohr","year":"2020","journal-title":"BMC Health Serv Res"},{"key":"2026031307301159000_31.2.121.8","unstructured":"Office of Rural Health, Department of Veterans Affairs . Rural Veteran Health Care Challenges, 2022. Available: https:\/\/www.ruralhealth.va.gov\/aboutus\/ruralvets.asp#:~:text=Almost%20a%20quarter%20of%20all,to%20reside%20in%20rural%20communities"},{"key":"2026031307301159000_31.2.121.9","doi-asserted-by":"publisher","DOI":"10.1176\/ajp.151.3.421"},{"key":"2026031307301159000_31.2.121.10","unstructured":"National Coalition for Homeless Veterans . Veteran Homelessness, Available: https:\/\/nchv.org\/veteran-homelessness"},{"key":"2026031307301159000_31.2.121.11","doi-asserted-by":"publisher","DOI":"10.1093\/epirev\/mxu004"},{"key":"2026031307301159000_31.2.121.12","doi-asserted-by":"publisher","DOI":"10.1016\/j.amepre.2016.06.001"},{"key":"2026031307301159000_31.2.121.13","doi-asserted-by":"crossref","first-page":"S40","DOI":"10.2105\/AJPH.2011.300481","article-title":"Characteristics of suicides among US army active duty personnel in 17 US states from 2005 to 2007","volume":"102 Suppl 1","author":"Logan","year":"2012","journal-title":"Am J Public Health"},{"key":"2026031307301159000_31.2.121.14","doi-asserted-by":"publisher","DOI":"10.15585\/mmwr.ss7105a1"},{"key":"2026031307301159000_31.2.121.15","unstructured":"Economic Research Service, US Department of Agriculture . Rural-Urban Commuting Area Codes, 2023. Available: https:\/\/www.ers.usda.gov\/data-products\/rural-urban-commuting-area-codes"},{"key":"2026031307301159000_31.2.121.16","unstructured":"Rural Health Research Center . RUCA Data, Available: https:\/\/depts.washington.edu\/uwruca\/ruca-uses.php"},{"key":"2026031307301159000_31.2.121.17","unstructured":"University of Wisconsin Population Health Institute . County health rankings national findings report 2023. 2023. Available: https:\/\/www.countyhealthrankings.org\/reports\/2023-county-health-rankings-national-findings-report"},{"key":"2026031307301159000_31.2.121.18","unstructured":"Centers for Disease Control and Prevention, National Violent Death Reporting System (NVDRS) Coding Manual . National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (producer), 2023. Available: www.cdc.gov\/injury"},{"key":"2026031307301159000_31.2.121.19","doi-asserted-by":"publisher","DOI":"10.1002\/mpr.329"},{"key":"2026031307301159000_31.2.121.20","doi-asserted-by":"crossref","DOI":"10.18637\/jss.v045.i03","article-title":"Multivariate Imputation by Chained Equations in R","volume":"45","author":"Buuren","year":"2011","journal-title":"J Stat Softw"},{"key":"2026031307301159000_31.2.121.21","unstructured":"Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration . Results from the 2021 National Survey on Drug Use and Health: Detailed Tables, 2022. Available: https:\/\/www.samhsa.gov\/data\/sites\/default\/files\/reports\/rpt39441\/NSDUHDetailedTabs2021\/NSDUHDetailedTabs2021\/NSDUHDetailedTabs2021.pdf"},{"key":"2026031307301159000_31.2.121.22","unstructured":"American Psychological Association . Survey says: More Americans are seeking mental health treatment, 2004. Available: https:\/\/www.apa.org\/monitor\/julaug04\/survey"},{"key":"2026031307301159000_31.2.121.23","unstructured":"Number of U.S. adults who received mental health treatment or counseling in the past year from, 2002. Available: https:\/\/www.statista.com\/statistics\/794027\/mental-health-treatment-counseling-past-year-us-adults\/#:~:text=In%202021%2C%20around%2041.7%20million,the%20use%20of%20prescription%20medication"},{"key":"2026031307301159000_31.2.121.24","doi-asserted-by":"publisher","DOI":"10.1017\/cts.2020.42"},{"key":"2026031307301159000_31.2.121.25","doi-asserted-by":"publisher","DOI":"10.1111\/j.1748-0361.2010.00291.x"},{"key":"2026031307301159000_31.2.121.26","doi-asserted-by":"publisher","DOI":"10.1007\/s10488-006-0105-8"},{"key":"2026031307301159000_31.2.121.27","doi-asserted-by":"crossref","DOI":"10.1186\/s13033-017-0154-2","article-title":"Lack of access to mental health services contributing to the high suicide rates among veterans","volume":"11","author":"Hester","year":"2017","journal-title":"Int J Ment Health Syst"},{"key":"2026031307301159000_31.2.121.28","doi-asserted-by":"publisher","DOI":"10.1097\/NMD.0000000000001139"},{"key":"2026031307301159000_31.2.121.29","doi-asserted-by":"publisher","DOI":"10.1016\/S2468-2667(21)00159-6"},{"key":"2026031307301159000_31.2.121.30","unstructured":"Rural Health Research Center . Substance Use and Misuse in Rural Areas, 2023. Available: https:\/\/www.ruralhealthinfo.org\/topics\/substance-use"},{"key":"2026031307301159000_31.2.121.31","doi-asserted-by":"publisher","DOI":"10.1136\/injuryprev-2013-040969"},{"key":"2026031307301159000_31.2.121.32","doi-asserted-by":"publisher","DOI":"10.1016\/S1359-1789(97)00057-8"},{"key":"2026031307301159000_31.2.121.33","doi-asserted-by":"publisher","DOI":"10.1370\/afm.2522"},{"key":"2026031307301159000_31.2.121.34","doi-asserted-by":"crossref","first-page":"e525","DOI":"10.1093\/milmed\/usaa495","article-title":"Firearm Suicide Among Veterans of the U.S","volume":"186","author":"Theis","year":"2021","journal-title":"Military: A Systematic Review Military Medicine"},{"key":"2026031307301159000_31.2.121.35","doi-asserted-by":"crossref","first-page":"878","DOI":"10.1016\/S0140-6736(07)61239-2","article-title":"Resources for mental health: scarcity, inequity, and inefficiency","volume":"370","author":"Saxena","year":"2007","journal-title":"The Lancet"},{"key":"2026031307301159000_31.2.121.36","doi-asserted-by":"crossref","unstructured":"Fernandez JM , Jayawardhana J . Are suicides underreported? The impact of coroners versus medical examiners on suicide reporting. Health Serv Res 2024. doi:10.1111\/1475-6773.14381","DOI":"10.1111\/1475-6773.14381"}],"container-title":["Injury Prevention"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/ip-2024-045430","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,13]],"date-time":"2026-03-13T18:47:00Z","timestamp":1773427620000},"score":1,"resource":{"primary":{"URL":"https:\/\/injuryprevention.bmj.com\/lookup\/doi\/10.1136\/ip-2024-045430"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,2,26]]},"references-count":36,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2025,3,20]]},"published-print":{"date-parts":[[2025,4]]}},"alternative-id":["10.1136\/ip-2024-045430"],"URL":"https:\/\/doi.org\/10.1136\/ip-2024-045430","relation":{},"ISSN":["1353-8047","1475-5785"],"issn-type":[{"value":"1353-8047","type":"print"},{"value":"1475-5785","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,2,26]]}}}