County-level social determinants of health and suicide mortality trends among formerly incarcerated persons in North Carolina, 2010–2018

Suicide mortality represents a growing public health crisis in the United States, disproportionately affecting people with recent incarceration histories. The purpose of this study was to assess how county-level Social Determinants of Health—including educational attainment, unemployment, poverty, aging, racial composition, and rurality—are associated with suicide mortality among formerly incarcerated individuals in North Carolina in order to develop geographically focused, socially responsive suicide prevention resources. We conducted a retrospective cohort study of people released from North Carolina prisons between 2010 and 2018 and compared suicide mortality with that of the North Carolina general population aged 18–69 years. Using linked administrative data, we calculated age-, sex-, and year-standardized suicide mortality rates and standardized mortality ratios (SMRs) by county-level social determinants of health, including educational attainment, unemployment, poverty, aging, racial composition, and rurality. Suicide mortality among formerly incarcerated individuals was consistently higher than in the general population, with the greatest disparities in counties that are urban (SMR: 2.04, 95% CI: 1.50, 2.58), have below average educational attainment (SMR: 2.53, 95% CI: 1.69,3.37), below average unemployment (SMR: 2.33, 95% CI: 1.66, 3.01), low poverty (SMR: 2.13, 95% CI: 1.56, 2.70), below-average racial diversity (SMR: 3.12, 95% CI: 2.20, 4.04), or an above-average proportion of older adults (SMR: 2.40, 95% CI: 1.22, 3.57). These findings suggest that suicide mortality disparities between formerly incarcerated individuals and the general population are greatest in more advantaged counties, where community-level protective factors appear to benefit the general population but do not extend to those returning from prison. Addressing these disparities will require investments in place-based mental health infrastructure and reentry support tailored to local community contexts.