National Changes in Number of Community Mental Health Centers and Suicide Rates
Figure 1 shows national changes in the number of CMHCs and suicide mortality rates during the period from 2014–2017. When only looking at the annual trend across all states, the number of CMHCs decreased from 3,406 to 2,920 while suicide mortality rates increased from 15.37 to 16.85 per 100,000 persons. For the four years from 2014 to 2017, these changes amounted to a 14.27% decrease in the number of CMHCs and a 9.63% increase in suicide mortality rates.
State-level Changes in Community Mental Health Centers and Suicide
National data obscures state variation in both numbers of CMHCs and changes in suicide rates. Between 2014 and 2017, over two-thirds of states experienced decreased numbers of CMHCs (Table 1). Percentage changes in the number of CMHCs ranged from − 58.3% in Alaska to + 92.86% in Wyoming. Despite the increasing trend in suicide rates nationally, 6 states have improved suicide mortality rates between 2014 and 2017; still, changes in suicide mortality rates varied substantially by state with percentage changes ranging from − 18.9% in DC to + 32.0% in South Dakota. Of all 50 states and DC, 33 (64.7%) simultaneously experienced a decrease in the number of CMHCs and an increase in suicide mortality rates between 2014 and 2017. In contrast, several states – CA, DC, DE, NJ, NY – had significant decreases in the number of CMHCs without a concurrent increase in suicide mortality rates. Similarly, some states –SC, SD, TN, TX, UT, VA, WA, WI, WV, WY – had an increased number of CMHCs but still experienced higher suicide rates. Per capita, there was a 16-fold variation in the number of CMHCs across states in 2014 (Appendix Table 2), ranging from 0.37 per 100,000 in North Carolina to 5.86 per 100,000 in Montana in 2014. Between 2014 and 2017, this variation dramatically increased to 25-fold, when the number of CMHCs per 100,000 decreased in most states (n = 40; 78.4%).
Table 1. Change in the Number of Community Mental Health Centers and Suicide Mortality Rates by State, 2014-2017
|
|
Number of Community Mental Health Centers
|
Suicide Mortality Rates
|
2014
|
2017
|
% Change 2014-2017
|
2014
|
2017
|
% Change 2014-2017
|
Nationwide
|
3406
|
2920
|
-14.27%
|
15.37
|
16.85
|
9.63%
|
AK
|
36
|
29
|
-19.44%
|
22.67
|
27.03
|
19.25%
|
AL
|
78
|
70
|
-10.26%
|
14.74
|
17.15
|
16.35%
|
AR
|
91
|
80
|
-12.09%
|
17.5
|
21.00
|
20.02%
|
AZ
|
55
|
32
|
-41.82%
|
18.6
|
18.91
|
1.68%
|
CA
|
157
|
104
|
-33.76%
|
10.99
|
10.91
|
-0.76%
|
CO
|
82
|
89
|
8.54%
|
20.41
|
21.06
|
3.20%
|
CT
|
31
|
34
|
9.68%
|
10.57
|
11.29
|
6.78%
|
DC
|
7
|
7
|
0.00%
|
8.35
|
6.77
|
-18.89%
|
DE
|
8
|
7
|
-12.50%
|
13.47
|
11.64
|
-13.56%
|
FL
|
156
|
101
|
-35.26%
|
15.35
|
15.38
|
0.18%
|
GA
|
65
|
41
|
-36.92%
|
12.91
|
13.91
|
7.77%
|
HI
|
15
|
8
|
-46.67%
|
14.58
|
15.90
|
9.06%
|
IA
|
65
|
60
|
-7.69%
|
13.13
|
15.23
|
15.97%
|
ID
|
46
|
25
|
-45.65%
|
19.58
|
22.83
|
16.61%
|
IL
|
146
|
101
|
-30.82%
|
10.97
|
11.51
|
4.96%
|
IN
|
154
|
139
|
-9.74%
|
14.39
|
16.38
|
13.83%
|
KS
|
77
|
73
|
-5.19%
|
15.74
|
18.98
|
20.60%
|
KY
|
113
|
103
|
-8.85%
|
16.52
|
17.29
|
4.64%
|
LA
|
29
|
15
|
-48.28%
|
14.67
|
15.37
|
4.77%
|
MA
|
45
|
39
|
-13.33%
|
8.88
|
9.94
|
11.96%
|
MD
|
76
|
37
|
-51.32%
|
10.39
|
10.41
|
0.19%
|
ME
|
31
|
27
|
-12.90%
|
16.54
|
20.51
|
24.00%
|
MI
|
105
|
100
|
-4.76%
|
13.72
|
14.63
|
6.60%
|
MN
|
69
|
60
|
-13.04%
|
12.64
|
14.04
|
11.08%
|
MO
|
58
|
65
|
12.07%
|
16.89
|
18.83
|
11.47%
|
MS
|
109
|
89
|
-18.35%
|
12.83
|
14.91
|
16.23%
|
MT
|
60
|
44
|
-26.67%
|
24.52
|
29.61
|
20.74%
|
NC
|
37
|
29
|
-21.62%
|
13.71
|
14.81
|
7.99%
|
ND
|
4
|
7
|
75.00%
|
18.53
|
20.39
|
10.02%
|
NE
|
14
|
27
|
92.86%
|
13.39
|
14.32
|
6.96%
|
NH
|
27
|
31
|
14.81%
|
18.62
|
19.73
|
5.99%
|
NJ
|
91
|
82
|
-9.89%
|
8.91
|
8.83
|
-0.92%
|
NM
|
29
|
22
|
-24.14%
|
21.63
|
23.51
|
8.71%
|
NV
|
12
|
5
|
-58.33%
|
20.22
|
20.91
|
3.43%
|
NY
|
150
|
110
|
-26.67%
|
8.72
|
8.54
|
-2.01%
|
OH
|
210
|
168
|
-20.00%
|
12.95
|
14.92
|
15.25%
|
OK
|
64
|
59
|
-7.81%
|
19.06
|
19.23
|
0.90%
|
OR
|
43
|
35
|
-18.60%
|
19.75
|
19.91
|
0.83%
|
PA
|
107
|
88
|
-17.76%
|
14.3
|
15.85
|
10.86%
|
RI
|
23
|
17
|
-26.09%
|
10.8
|
12.17
|
12.72%
|
SC
|
50
|
59
|
18.00%
|
15.67
|
16.68
|
6.44%
|
SD
|
26
|
25
|
-3.85%
|
16.64
|
21.96
|
31.99%
|
TN
|
104
|
86
|
-17.31%
|
15.25
|
17.36
|
13.85%
|
TX
|
109
|
124
|
13.76%
|
12.16
|
13.35
|
9.77%
|
UT
|
31
|
35
|
12.90%
|
19.03
|
21.37
|
12.32%
|
|
Number of Community Mental Health Centers
|
Suicide Mortality Rates
|
2014
|
2017
|
% Change 2014-2017
|
2014
|
2017
|
% Change 2014-2017
|
VA
|
87
|
87
|
0.00%
|
13.55
|
13.92
|
2.73%
|
VT
|
27
|
25
|
-7.41%
|
19.79
|
17.96
|
-9.25%
|
WA
|
89
|
113
|
26.97%
|
15.97
|
17.51
|
9.66%
|
WI
|
37
|
29
|
-21.62%
|
13.37
|
15.98
|
19.51%
|
WV
|
43
|
55
|
27.91%
|
19.73
|
21.64
|
9.69%
|
WY
|
28
|
23
|
-17.86%
|
20.54
|
27.10
|
31.94%
|
SOURCE Data were from 2014-2017 National Mental Health Services Survey (N-MHSS) to identify state-level mental health facility status during 2014-2017 and from Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) data for suicide rates, identified as intentional self-harm by ICD-10-CM diagnosis codes U03, X60-X71, X72-X74, X75-X84, Y87.0. NOTE A Community Mental Health Center was defined as a facility that provided any of the following services: 1) outpatient services, 2) 24-hour emergency care services, 3) day treatment or other partial hospitalization services, or psychosocial rehabilitation services, and 4) screening for inpatient services to state mental health facilities, and that met applicable licensing or certification requirements for community mental health centers in a state where it is located (
7). Mental health care facilities self-identified as a partial hospitalization or day treatment facility were also categorized as a community mental health center.
Table 2
Associations between State-level Mental Health Services Capacity and Suicide Mortality Rates 2014–2017
| Coefficients [95% Confidence Interval] |
Model 1 | Model 2 | Model 3 | Model 4 |
Between-state Model | Add State & Time | Add Age and Race | Add Low-income |
State Indicators Included | No | Yes | Yes | Yes |
Number of Community Mental Health Centers Per 100,000 Persons | 2.78 (2.36, 3.20) *** | -0.52 (-1.03, -0.02)* | -0.60 (-1.09, -0.11)* | -0.52 (-1.08, 0.03)§ |
Number of Hospital Psychiatric Care Settings per 100,000 Persons | -1.70 (-2.54, -0.85) *** | 0.75 (-0.72, 2.21) | 1.32 (-0.03, 2.67)§ | 1.39 (0.02, 2.75)* |
Number of 100 Mental Health Professionals per 100,000 Persons† | -0.71 (-1.26, -0.16)* | 0.10 (-0.21, 0.41) | -0.10 (-0.51, 0.30) | -0.10 (-0.46, 0.26) |
Year (Reference: 2014) | | | | |
2015 | | 0.27 (0.20, 0.34)*** | 0.52 (0.32, 0.73)*** | 0.45 (0.27, 0.63)*** |
2016 | | 0.39 (0.31, 0.48)*** | 0.91 (0.50, 1.31)*** | 0.52 (0.17, 0.87)** |
2017 | | 0.80 (0.67, 0.93)*** | 1.67 (1.14, 2.20)*** | 1.17 (0.69, 1.65)*** |
% Persons Below 200% Federal Poverty Level | | | | -0.09 (-0.14, -0.04)** |
% Population by Age Group | | | | |
Less than 15 Years Old | | | Ref | Ref |
15–24 Years Old | | | 1.02 (0.63, 1.42)*** | 0.63 (0.21, 1.06)** |
25–44 Years Old | | | -0.15 (-0.55, 0.25) | -0.94 (-1.34, -0.53)*** |
45–64 Years Old | | | -1.27 (-1.57, -0.97)*** | -1.82 (-2.41, -1.23)*** |
65–74 Years Old | | | -0.14, -0.92, 0.64) | -0.41 (-1.15, 0.32) |
75 Years Old or More | | | -1.50 (-2.56, -0.45)** | -1.81 (-2.53, -1.10)*** |
% Population by Race/Ethnicity | | | | |
Non-Hispanic White | | | Ref | Ref |
Non-Hispanic Black | | | 0.84 (0.73, 0.94)*** | 0.93 (0.67, 1.18)*** |
American Indian and Alaska Native | | | 1.45 (-0.74, 10.33) | -0.98 (-10.24, 8.28) |
Asian | | | -1.70 (-2.28, -1.12)*** | -1.67 (-2.15, -1.18)*** |
Native Hawaiian and Pacific Islander | | | 21.47 (16.58, 26.37)*** | 22.49 (18.01, 26.96)*** |
Hispanic | | | -1.43 (-1.61, -1.25)*** | -1.41 (-1.58, -1.24)*** |
Two or More Races | | | -1.48 (-1.86, -1.10)*** | -1.42 (-1.79, -1.05)*** |
NOTES Data were from 2014–2017 National Mental Health Services Survey (N-MHSS) to identify state-level mental health facility availabilities during 2014–2017 and from Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) data for suicide rates, identified as intentional self-harm by ICD-10-CM diagnosis codes U03, X60-X71, X72-X74, X75-X84, Y87.0. Significance at p-values of § p < .1, * p < .05, **p < .01, ***p < .001 were noted for the average marginal effects of suicide mortality rates per a unit increase for continuous variables, switching from the reference group, accounting for intra-state correlation across years. Estimates were derived from multivariate linear regression models, weighted by state population size. †Data on mental health professionals, including psychiatrists, psychiatric technicians, psychiatric aides, clinical, counseling, and school psychologists, all other psychologists, mental health counselors, mental health and substance abuse social workers, were derived from U.S. Bureau of Labor Statistics (42). |
Between-State Association between Community Mental Health Centers and Suicide
Figure 2 graphically depicts the between-state associations between the 2014–2017 state average CMHC availability per 100,000 and state average suicide rate per 100,000. These data indicate that states with more CMHC availability have higher suicide rates. <Insert Fig. 2 About Here>
Multivariate Analysis of Community Mental Health Centers and Suicide
The results of multivariate time series models are shown as average marginal effects, indicating the estimated annual change in suicide deaths per 100,000 persons associated with a one-unit increase for continuous variables (Table 2). The first model shows a significant positive between-state association between the availability of CMHCs and suicide rates, as one would expect based on Fig. 2 (Table 2; Model 1). In contrast, states with higher supply of hospital-based psychiatric units or with more mental health professionals per capita had lower suicide rates. However, after controlling for time-invariant differences between states and underlying time trends (Table 2; Model 2), we estimated that one additional CMHC per 100,000 persons was associated with a decrease in number of suicides (Average Marginal Effects: -0.52, 95% CI -1.03 to -0.02; p = 0.043). After adding controls for age, race, percent low-income, one CMHC increase per 100,000 persons was associated with a decrease of 0.52 suicide deaths per 100,000 persons (-0.52, 95% CI -1.08 to 0.03; p = 0.066). Additionally, increases in number of hospitals with psychiatric services and mental health professionals were associated with increases in state suicide mortality.
To better understand the magnitude of the associated suicide deaths with CMHC changes per capita, we consider the number of suicides that may have been prevented had the number of CMHCs not been reduced over this time period. Considering the population-weighted number of CMHCs decreased from 1.07 per 100,000 in 2014 to 0.90 per 100,000 in 2017 (Appendix Table 3), indicating 0.17 per 100,000 fewer CMHCs nationally. The estimated effect in Model 4 (-0.52) suggests the change in CMHC would lead to 0.0697 additional suicides per 100,000 (-0.17× -0.52 = 0.0884. Given 1.48 per 100,000 more suicides between 2014 and 2017 (15.37 and 16.85 per 100,000, respectively), this accounts for 6.0% of the increase in suicides over the four-year period (0.0884/1.48). With the national increase in 4,400 suicide deaths from 2014 (42,773) to 2017 (47,173) (1), this represents 263 additional suicide deaths following the loss of CMHCs (6.0%×4,400 = 262.8).
State-level age, race, and low-income distribution were expected not to change significantly over the four study years and therefore would not be significantly associated with the changes in suicide rates during 2014–2017. Yet, we observed a positive association between increased suicide rates and the higher proportion of individuals in a given state who were Black (0.93, 95% CI 0.67 to 1.18]; p < .001) or Native Hawaiian and Pacific islanders (22.49, 95% CI 18.01 to 26.96]; p < .001), and a negative association between decreased suicide rates and the higher proportion of the individuals who were Asian (-1.67, 95% CI -2.15, -1.18; p < .001), Hispanic (-1.41, 95% CI -1.58, -1.24; p < .001), or two or more races (-1.42, 95% CI -1.79, -1.05; p < .001).
To further illustrate the within-state associations between the number of CMHCs per 100,000 persons and suicide rates we find in the final model (i.e., Model 4), we calculated adjusted suicide rates, controlling for hospital-based psychiatric supply, mental health professional supply, age, race, and % low-income in a state, state fixed effects, and year. These adjusted rates have already controlled for underlying time trends in suicide rates, and the average suicide rate in each state over the time period studied. We then plotted the four predicted suicide rates for each state, with a line indicating results for the same state (Fig. 3). This figure demonstrates that, controlling for the underlying increase in suicide trends nationwide, within states, positive (negative) changes in CMHCs are associated with smaller (greater) changes in suicide.