Are high suicide rates in rural America linked to high death rates among working-class whites?

The New York Times reported last week on high and rising suicide rates in rural and small-town America. Laura Beil's story, based on a study published in the May issue of JAMA Pediatrics, emphasized, to some extent, the young.  She reports that rural adolescents commit suicide at about twice the rate of urban adolescents.  Beil notes that "imbalances between city and country have long persisted," and quotes Cynthia Fontanella, a psychologist at Ohio State University, the study's lead author:

We weren’t expecting that the disparities would be increasing over time.  The rates are higher, and the gap is getting wider.

But Beil also talked about older cohorts of rural residents:

Suicide is a threat not just to the young. Rates over all rose 7 percent in metropolitan counties from 2004 to 2013, according to the Centers for Disease Control and Prevention. In rural counties, the increase was 20 percent. 

The problem reaches across demographic boundaries, encompassing such groups as older men, Native Americans and veterans. The sons and daughters of small towns are more likely to serve in the military, and nearly half of Iraq and Afghanistan veterans live in rural communities.

The Sacramento Bee subsequently ran this story about suicide rates by county in California.  It shows a similar trend toward higher rates in nonmetropolitan counties.

On the same day as the NYT story on rural suicides, the paper also covered this story, which has received a lot more attention in the ensuing period:  the release of the Deaton-Case study on life expectancy, reported under the headline "Death Rate Rising for Middle-Age White Americans, Study Finds."  The NYT did not seem to link these two--at least not explicitly--but to me they seemed obviously related.

Here's the lede for the latter story:

Something startling is happening to middle-aged white Americans. Unlike every other age group, unlike every other racial and ethnic group, unlike their counterparts in other rich countries, death rates in this group have been rising, not falling. 

* * * 

Analyzing health and mortality data from the Centers for Disease Control and Prevention and from other sources, they concluded that rising annual death rates among this group are being driven not by the big killers like heart disease and diabetes but by an epidemic of suicides and afflictions stemming from substance abuse: alcoholic liver disease and overdoses of heroin and prescription opioids.

* * * 

In contrast, the death rate for middle-aged blacks and Hispanics continued to decline during the same period, as did death rates for younger and older people of all races and ethnic groups. 

Middle-aged blacks still have a higher mortality rate than whites — 581 per 100,000, compared with 415 for whites — but the gap is closing, and the rate for middle-aged Hispanics is far lower than for middle-aged whites at 262 per 100,000.

First, let us be clear that this study is not about middle-aged whites generally.  It is about middle aged, working class whites--those with no more than a high school education.  Between 1999 and 2014, their death rate increased by 134 deaths per 100,000.  According to commentary, this is a shift of considerable magnitude.  Many are speculating about the "why" behind this data.  Dr. Deaton said he "envisions poorly educated middle-aged white Americans who feel socially isolated are out of work, suffering from chronic pain and turning to narcotics or alcohol for relief, or taking their own lives."

So, what do the two news stories have to do with each other?  I suspect that a higher rate per capita of working class whites plagued by these health problems are living in rural America--or at least a disproportionate share of those who succumb to suicide or overdoses likely are.  Certainly the heroin and opioid epidemics have been associated with nonmetropolitan areas, though they are by no means exclusively rural phenomena.  See more here and here.  Further, the first story (the one focusing on rural suicides) suggests that rural Americans--no doubt including many middle age, working class white ones, some of whom are veterans (see more about rural veterans service access issues here, here and here)--are without adequate mental health resources, meaning they are more likely to succumb to drug abuse, alcoholism, and other problems associated with early mortality among this demographic slice.  We should think not only about the public health problem of a spiking death rate among working class whites, we should think about how to improve service provision and access to rural Americans.

See stories related to the Deaton-Case study here and here and commentary on the study here, here, here, here, here, here, here, here, here, and here.