The results of this study show a direct relationship between the proportion of funds that a state allocates for state hospitals and the suicide rate. The suicide rate was lower in states in which the percentage of funds allocated to state hospitals and to community-based services were close to the optimum theoretical proportions. The finding that, on average, the 50 states are moving toward this optimum ratio of funding supports the notion that there might be "wisdom in the mean."
According to data from the NASMHPD Research Institute, the states that spent the greatest amount on mental health care in fiscal year 1997—that is, between $75 and $115 per capita—are Washington, Montana, Minnesota, Michigan, New York, Vermont, New Hampshire, Massachusetts, Connecticut, Maine, Rhode Island, and Alaska. According to our model, Minnesota, Michigan, New York, Massachusetts, Connecticut, Rhode Island, and New Hampshire appear to be obtaining full value for their state hospital appropriation. On the other hand, Montana, Vermont, Washington, and Alaska are not achieving as good a result as their level of state hospital funding would suggest, at least as measured by the suicide rates in those states. It may not be coincidental that these five states are located in the northern United States. The widely variable light-dark cycle in these states—the seasonal effect—may affect rates of depression and other mental illnesses (
+4). It may take even more funding or more effective treatments to negate such effects.
According to the NASMHPD data, the states spending the least for behavioral health care—less than $40 per capita—are Texas, New Mexico, Colorado, Idaho, Nebraska, Missouri, Kansas, Tennessee, Kentucky, Illinois, and West Virginia. Our model indicates that Texas, Nebraska, Kansas, and Illinois are obtaining good value for their relatively low level of mental health care funding because their suicide rates are low. Colorado, Idaho, Kentucky, and Missouri, where the suicide rates are higher than average even though the funding levels for state hospitals are not far out of line with the optimum, would probably benefit from increased funding. Tennessee, Maine, and West Virginia, where funding for state hospitals exceeds the optimum, might benefit from increased spending on community-based services. On the other hand, increased funding for state hospitals in New Mexico might allow hospital staff to better stabilize patients during an intensive, tertiary hospital stay.
It should be noted that these suggestions are based on 1997 data, which were the most current data available when we constructed our model. Conditions in some of the states mentioned are almost certainly different now. Nevertheless, we believe that the same methodology can be used with current data. We also emphasize that our study did not attempt to catalogue all the causes of suicide. Rather, we attempted to demonstrate that features of the mental health care delivery system may play a role in altering the suicide rate, whatever the causes of suicide.
The R
2 value of the model is admittedly low at about 8 percent. (This statistic represents the percentage of the variation predicted by the regression line, a perfect match being unity.) However, in the absence of a clear strategy based on any scientific principle, the states have had little guidance in their management of funding. Therefore, we would expect considerable scatter in
+Figure 1. We would expect the R
2 value to increase as states approach the ideal ratio for funding.
There appears to be a gradient in the suicide rate in the United States, with the rate increasing from the East to the West Coast (
+5). Genetics may partly explain this phenomenon: people who are likely to move toward the frontier may be those who are innately dissatisfied with the status quo and, being deprived of new challenges, may have a tendency toward depression and an elevated risk of suicide. As noted above, a much weaker latitudinal effect may have an impact on inhabitants of northern states. In addition, the suicide rate is probably affected by regional societal attitudes toward people with mental illness.
Although many genetic and environmental factors affect the suicide rate, the organizational structure of behavioral health services appears to play a significant role. The results of this study suggest that the proper allocation of funds between state hospitals and community-based facilities is important in minimizing the suicide rate.