Exploring social, economic, and environmental correlates of suicide in Puerto Rico, 2017–2022: an ecological cross-sectional study

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BACKGROUND: Puerto Rico (PR) endures numerous natural and human-caused disasters with significant impacts on community health and infrastructure each year. The Centers for Disease Control's Social Vulnerability Index (CDC-SVI) quantifies a community's capacity to prepare, respond, and recover from disasters. The SVI has been linked to all-cause mortality in the continental US, however, its relevance to suicide mortality, particularly in PR, remains understudied. METHODS: This cross-sectional study analyzed data from 1,471 suicide decedents recorded in the PR site of the National Violent Death Reporting System (NVDRS) from 2017 to 2022. Using Bayesian Poisson hierarchical models, we examined the associations between the county-level CDC-SVI with age- and sex-standardized suicide mortality. We explored whether contributing circumstances (i.e., mental health history, financial loss) varied by measure of SVI among these decedents. RESULTS: During 2017-2022, there were 1,471 suicides (Mean age: 51 years, 84% male, 68% lower education) across PR's 78 municipalities. Overall, there was no association between county CDC-SVI and suicide mortality (Relative Risk: 1.05, 95% CI: 0.88-1.25). The most common contributing circumstances (available for 93% of decedents) were mental health problems (45%), depressed mood (44%), history of mental health treatment (29%), and prior suicide attempt (28%) or suicidal thoughts (26%). Our geospatial analyses revealed a clustering of suicide and vulnerability in central counties and island-municipalities, areas marked by long-standing economic disadvantage and limited access to healthcare. CONCLUSIONS: Social vulnerability was unrelated to suicide mortality, contrasting with prior studies in the continental US. While the CDC-SVI is a useful tool for disaster response planning, its utility for suicide prevention in PR depends on the local validity and relevance of its components. These results suggest that the contextual determinants of suicide in PR operate through different structural pathways, shaped by the island's distinct socioeconomic, demographic and disaster-exposed setting, where most communities already experience high vulnerability.

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