County‐level vulnerability is associated with mental health and substance use treatment among rural suicide decedents: A national multi‐year cross‐sectional study

PURPOSE: To examine the relationship between individual- and county-level factors associated with mental health and substance use dependence (MHSUD) treatment among rural suicide decedents. METHODS: Cross-sectional study (2013-2022) study of the National Violent Death Reporting System and the County Health Rankings. Primary exposures included individual- (demographic, clinical conditions) and county-level (average number of mentally unhealthy days, percentage of uninsured adults, rate of mental health providers/county, percentage of unemployed adults, rate of social associations, percentage of adults driving alone during long commutes, rate of primary care physicians/county, and income inequality ratios) factors of the decedent. The outcome was ever receipt of MHSUD treatment. We used multivariable logistic regression to measure the association between individual- and county-level factors and MHSUD treatment receipt. RESULTS: Of 42,021 rural suicides, 30% had MHSUD treatment receipt. Decedent-level factors associated with lower MHSUD treatment included male, sex, older age, racial/ethnic minorities, and residence in the Midwest or Northeast. MHSUD treatment was lower in rural counties with greater vulnerability (e.g., higher average number of mentally unhealthy days [aOR = 0.75, 95% CI: 0.68, 0.81], lower rate of primary care physicians/county [aOR = 0.92, 95% CI: 0.85, 0.99], lower rate of mental health providers/county [aOR = 0.76, 95% CI: 0.70, 0.81]). CONCLUSIONS: By focusing within rural US counties, we found considerable variability in county-level risk factors for MHSUD treatment among suicide decedents. Research and public health efforts may consider disaggregating county-level factors when tailoring rural suicide prevention interventions in addition to improving MHSUD clinical infrastructure for both vulnerable individuals and counties.