This issue of The CBHSQ Report uses combined 2013 to 2015 NSDUH data to present estimates of past year serious suicidal thought, suicide planning, and suicide attempts among those aged 18 or older who were residing in 33 metropolitan statistical areas (MSAs⁵), and is an update to an earlier report using 2008 to 2010 data.⁶ Table S1 provides a complete list of the MSAs analyzed in this report and the abbreviations used to identify each MSA in the maps and tables presented in this report. The MSAs included in this report were selected based on a combination of the MSAs with sufficient sample size to produce reliable estimates and the intent to get representation from the different Department of Health and Human Services regions of the country.⁷ 

All estimates of past year serious suicidal thought, suicide planning, and suicide attempts in this report are annual averages based on the combined 2013 to 2015 NSDUH data. Comparisons are made between each MSA and the nation as a whole. Only differences in estimates that are statistically significant at the .05 level are discussed in the text.⁸  When describing the lowest and the highest prevalence estimates, the term “range” is used if the lowest and the highest estimates are significantly different at the .05 level. Otherwise, the term “include” is used to describe some of the estimates.

Based on combined 2013 to 2015 NSDUH data, about 9.5 million adults aged 18 or older had serious thoughts of suicide in the past 12 months. This corresponds to a national estimate of about 1 in 25 (4.0 percent) adults having serious thoughts of suicide (Table 1). Percentages of adults who had suicidal thoughts ranged⁹ from 2.5 percent in the Miami MSA to 6.6 percent in the New Orleans MSA (Figure 1). Among the 33 MSAs, the percentages of adults who had suicidal thoughts were lower than the national average in Miami (2.5 percent), Chicago (2.9 percent), and Dallas (3.0 percent). No MSAs had percentages of adults with suicidal thoughts that were significantly higher than the percentage in the nation as a whole.

Table 1 in the previous section presented comparisons between the national average and MSA estimates of serious thoughts of suicide in the past year.  In this section, the MSA’s estimates of past year serious thoughts of suicide among adults aged 18 or older are presented on a national map (Figure 1). To produce the map in Figure 1, estimates for MSAs that were ordered from the highest to the lowest were then divided into four categories. An MSA having a higher or lower estimate does not imply that the estimate is significantly higher or lower than the next highest or lowest estimate. When comparing two estimates, overlapping 95 percent confidence intervals do not imply that the estimates are statistically equivalent at the 5 percent level of significance.¹⁰

Adults who had serious thoughts of suicide in the past 12 months were asked whether they made a plan to kill themselves in that period. Adults who had not had serious thoughts of suicide were considered to not have made a suicide plan. Nationwide, about 2.7 million adults aged 18 or older made any plans to commit suicide in the past 12 months. This corresponds to a national estimate of 1.1 percent of adults aged 18 or older (Table 1). In Figure 2, the MSA estimates of past year suicide planning among adults are presented. As previously noted, an MSA having a higher or lower estimate does not imply that the estimate is significantly higher or lower than the next highest or lowest estimate.¹⁰ Percentages of adults living in an MSA who had made suicide plans in the past year included⁹ 0.4 percent in the Atlanta MSA and 2.1 percent in the New Orleans MSA (Figure 2). Among the 33 MSAs, the percentages of adults living in MSAs who made a suicide plan were lower than the national average in Atlanta (0.4 percent), Houston (0.7 percent), Los Angeles (0.7 percent), and New York (0.8 percent). Again, no MSAs had percentages of adults with suicide plans that were significantly higher than the rate in the nation as a whole.

Adults who had serious thoughts of suicide in the past 12 months were asked whether they attempted to kill themselves in that period. Adults who had not had serious thoughts of suicide were considered to not have attempted suicide. Based on combined 2013 to 2015 data, about 1.3 million adults aged 18 or older made a suicide attempt in the past 12 months. This corresponds to a national estimate of about 1 in 200 (0.5 percent) adults attempting suicide in the past year (Table 1). In Figure 3, the MSA estimates of having had a past year suicide attempt among adults are presented. As previously noted, an MSA having a higher or lower estimate does not imply that the estimate is significantly higher or lower than the next highest or lowest estimate.¹⁰ Percentages of adults living in an MSA who had attempted suicide in the past year included⁹ 0.2 percent in the Albuquerque MSA and 1.0 percent in the Honolulu MSA (Figure 3). Among the 33 MSAs, Albuquerque (0.2 percent), Houston (0.3 percent), Philadelphia (0.3 percent), and Portland (0.3 percent) had lower percentages of adults who made suicide attempts than the nation as a whole. No MSAs had percentages of adults attempting suicide in the past year that were significantly higher than the rate in the nation as a whole.

Suicide is a public health problem that transcends geographical boundaries. Behind the statistics on completed suicides are the troubling large numbers of Americans who think about, plan for, and attempt suicide every year.² Although the prevalence of adults with serious thoughts of suicide, suicide plans, and suicide attempts among the MSA varies, it is important to note that there are many people with suicide ideation in every MSA; this is expected because suicide occurs throughout the United States.¹ The presence of suicide ideation in every MSA reinforces that suicide is a major public health concern.

Preventing suicide and addressing the health care needs of persons at risk for suicidal behavior require public health information–sharing efforts that raise awareness and explain that effective preventive interventions exist. Suicide touches all ages and backgrounds in all parts of the country. Highlighting the prevalence of suicidal thoughts, plans, and attempts in metropolitan areas may provide policymakers information to help inform their assessments of suicide ideation and other suicide behaviors in their communities. Further research on additional factors associated with geographic variations in the prevalence of suicidal behaviors is needed to help guide the development of screening tools and prevention and treatment programs.

SAMHSA uses a multifaceted approach to addressing suicide as a public health concern. SAMHSA works with its federal partners to address suicide prevention. For example, this report was developed in collaboration with and included funding from the Center for Disease Control.   SAMHSA also provide states, territories, tribal entities, communities, and the public with suicide prevention resources:

• National Suicide Prevention Lifeline     1-800-273-TALK (8255)
• Suicide Prevention Resource Center

1. Centers for Disease Control and Prevention (CDC). (2005). Web-based Injury Statistics Query and Reporting System (WISQARS) [Web page]. Retrieved August 7, 2017, from https://www.cdc.gov/injury/wisqars
2. Han, B., Kott, P.S., Hughes, A., McKeon, R., Blanco, C., & Compton, W.M. (2016). Estimating the rates of deaths by suicide among adults who attempted suicide in the United States.  Journal of Psychiatric Research, 77, 125-133.
3. Lipari, R. N., Hughes, A., & Williams, M. (2016, June). State estimates of past year serious thoughts of suicide among young adults: 2013 and 2014. The CBHSQ Report. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/
4. Centers for Disease Control and Prevention. (2016). Youth risk behavior surveillance—United States, 2015. Morbidity and Mortality Weekly Report, 65(SS-6), 1–174. Retrieved from http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf.
5. MSAs are geographical entities used by federal agencies to collect, analyze, and publish statistical data. These areas are defined and updated periodically by the Office of Management and Budget (OMB). MSAs defined in this report are based on updates made by OMB on February 28, 2013, to reflect Census Bureau population estimates for July 1, 2011, and July 1, 2012.
6. Center for Behavioral Health Statistics and Quality. (2012, October). Suicidal thoughts and behavior in 33 metropolitan statistical areas: 2008 to 2010. The NSDUH Report. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/
7. More information on the Department of Health and Human Services regional designations is available at U.S. Department of Health and Human Services. (2012). HHS region map. Retrieved from http://www.hhs.gov/about/agencies/iea/regional-offices/index.htmlregionmap.html.
8. For some MSAs, the difference from the national estimate may appear larger than some of those noted in the text and figures; however, because of the larger variances in the MSAs, the differences are not statistically significant.
9. When describing the lowest and the highest prevalence estimates, the term “range” is used if the lowest and the highest estimates are significantly different at the .05 level. Otherwise, the term “include” is used to describe some of the estimates.
10. In this report, MSA estimates are discussed in terms of their observed rankings because they provide useful context. However, an MSA having a highest or lowest rate does not imply that the given MSA's rate is significantly higher or lower than the rate of the next highest or lowest MSA. Similarly, the four categories were not selected to represent statistical differences across the categories or to correspond to proximity to a target public health threshold for a particular measure. When comparing two MSA prevalence rates, the method of overlapping confidence intervals is more conservative (i.e., it rejects the null hypothesis of no difference less often) than the standard method based on Z statistics when the null hypothesis is true. Even if confidence intervals for two MSAs overlap, the two estimates may be declared significantly different by the test based on Z statistics. Hence, the method of overlapping confidence intervals is not recommended to test the difference of two state estimates. A detailed description of the method of overlapping confidence intervals and its comparison with the standard methods for testing of a hypothesis is given in the following articles: (a) Schenker, N., & Gentleman, J. F. (2001). On judging the significance of differences by examining the overlap between confidence intervals. American Statistician, 55(3), 182–186. (b) Payton, M. E., Greenstone, M. H., & Schenker, N. (2003). Overlapping confidence intervals or standard error intervals: What do they mean in terms of statistical significance? Journal of Insect Science, 3, 34. For details on a more accurate test to compare state prevalence estimates, please see Section B.12 in Appendix B of 2011-2012 National Survey on Drug Use and Health: Guide to state tables and summary of small area estimation methodology, located at https://www.samhsa.gov/data/report/2011-2012-nsduh-state-estimates-substance-use-and-mental-disorders.

Park-Lee, E., Hedden, S. L., and Lipari, R. N. Suicidal Thoughts and Behavior in 33 Metropolitan Statistical Areas Update: 2013 to 2015. The CBHSQ Report: March 14, 2018. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, MD.