A Cultural Script for Suicide among White Men in the Mountain West Region of the United States

Abstract

The states of the Mountain West region of the United States consistently have the highest rates of suicide in the country, a pattern particularly pronounced in older White men. Although multiple constructs have been proposed to explain this long-standing pattern, including social isolation, cultural values, and psychopathology, relatively little research has been conducted to directly examine the predictive role of these risk factors and how they interact. We review the extant research for these constructs to establish 1. whether the risk factor occurs at a higher rate or is otherwise more influential in this region compared to the rest of the country and 2. whether the risk factor may account for specific effects in older White men in order to determine whether the evidence supports the role of each risk factor in understanding the high rates of suicide among older White men in this region. Using the results of this review, we then present a possible cultural script for suicide based on Cultural Scripts of Gender and Suicide Theory (Canetto, 1997, 2017, 2021) that describes who dies by suicide, the methods they use, their emotions and motives, and the cultural understanding of the causes and acceptability of their suicidal behaviors within the Mountain West. This cultural script can serve as a guide for researchers investigating the complex mechanisms that account for elevated rates of suicide in this region.

The Mountain West region consistently has the highest suicide rates in the United States (Amin et al., 2022), dating back to the 19^th century (Lester, 1997). The region is often defined by the U.S. Census Bureau Mountain Division (U.S. Census Bureau, 1994) as including Idaho, Montana, Utah, Wyoming, Nevada, Colorado, Arizona, and New Mexico. In 2021, the states with the highest suicide rates per capita in the country were Wyoming, Montana, Alaska, New Mexico, and Colorado. All 8 Mountain Division states were within the top 17 states with the highest suicide rates in the country (Drapeau & McIntosh, 2023).

Many risk factors have been proposed to account for regional differences in suicide rates. We will consider these risk factors through the lens of a cultural script. Canetto argues that cultures differ throughout the world in their understanding of suicides (Canetto, 2008; Canetto & Sakinofsky, 1998). According to Canetto (2021):

A suicide script is about the scenario of the suicidal act—including the suicidal person, the method, the emotions and motives expressed by or attributed to the suicidal individual, as well as the precipitant, outcome (nonfatal versus fatal), and responses to the suicidal act. A suicide script is also about the meanings of the suicidal act, including beliefs about the causes of suicidal behavior, and attitudes about its acceptability…

(pp. 1049–1050)

Importantly, cultural scripts are not consciously followed by individuals exhibiting a specific behavior. Instead, they describe the cultural understanding of the behavior. For example, unlike most countries where men are two to four times as likely as women to die by suicide, until 2000, rural Chinese women were more likely than men to die by suicide, using pesticide poisoning to escape abuse from families into which they have married (e.g., Meng, 2002). The cultural explanation of who dies by suicide, using what means, and for what reasons, define the cultural script for suicide in rural China. In this paper, we aim to describe the cultural script for suicide among older, non-Hispanic White men in the Mountain West. When data are available, we will particularly focus on older White men. Although suicide rates are elevated in this region across all races, ages, and sexes (Pepper, 2017), they are particularly high among older White men and Indigenous Peoples. Although our review focuses on White men, we recognize that Indigenous Peoples have distinct cultural scripts for suicide that remain understudied (Wexler & Gone, 2012).

Methods

There is some controversy about how to define the Mountain West region. For this review, we focus primarily on the states of the U. S. Census Mountain Division, although some data capture neighboring states and Alaska, which share high suicide rates and a frontier culture with parts of the Mountain West. Other data collapse the Mountain West with the Pacific West, including Alaska, Washington, Oregon, California, and Hawaii.

Using Canetto’s (1997, 2017, 2021) cultural scripts of gender and suicide theory as a frame, we reviewed the literature to explicate how these risk factors may define a regional understanding of suicide for older White men and guide future research to test this framework. We searched the literature using PSYCINFO, ERIC, PubMed, and Academic Search Premier, for articles on Suicide, Suicidality, and Mountain West, West, Region, Geography, States, and U.S.A or United States or U.S. or United States of America. Using a snowballing approach, we expanded the search to other fields, including sociology, geography, and marketing to develop a list of possible explanatory constructs. We also examined geographic maps of other risk factors commonly associated with suicide (e.g., poverty, divorce) to determine whether the phenomena were systematically elevated in the Mountain West. For each identified risk factor, we then examined 1). The evidence that the risk factor itself is more pervasive or otherwise influential in the Mountain West compared to the rest of the country and 2). The evidence that the phenomena particularly affects White men. Some risk factors were eliminated from further consideration due to a lack of evidence of elevations in the Mountain West (e.g., divorce, poverty, unemployment, and risk-taking). Drawing on Canetto’s (1997, 2017, 2021) cultural scripts of gender and suicide theory, we interpreted the findings of our narrative review and proposed explanations for how the reviewed risk factors may define a regional understanding of suicide for White men and may guide future research. We will begin by examining individual factors, including psychopathology, culture of honor, and firearms before moving to contextual factors. See Table 1 for a summary of our findings.

Table 1.

Summary of Literature Review Findings

Variable	Weight of evidence for or against role in region	Demographic evidence in region	Direct or indirect	Conclusion
Major depression	Moderate no effect	No specific effects	Direct	-Moderate evidence of no effect on regional suicide patterns
Substance Use Disorders	Weak for alcohol Moderate for drugs	No specific effects	Direct	-Moderate evidence of substance use contributing to regional suicides in men, not specific to older White men
Substance Use	Weak for	No specific effects	Direct	-Weak evidence of substance use contributing to regional suicides, not specific to older White men
Culture of Honor	Moderate for	Some specific effects for older White men	Indirect	-Moderate evidence that CoH contributes to suicides in region
Firearms	Moderate for	Some specific effects for White men	Direct	-Moderate evidence that firearms contribute to suicides in older White men in region, but effects are not unique to region
Population density	Weak mixed	No specific effects	Indirect	-Mixed evidence that low population density plays a role
Economic factors	Moderate for	Some specific effects for men	Indirect	-Moderate
Residential stability	Moderate for	No specific effects	Direct	-Moderate evidence that low residential stability contributes to regional suicides
Religion	Weak for	No specific effects	Indirect	-Limited evidence suggest low religiosity plays a role, but mechanisms are unclear
Altitude	Moderate for	No specific effects	Indirect	-Strong evidence that altitude contributes to regional suicide, but weak evidence for mechanisms
Areas needing further research
Stigma	No evidence	No evidence		-No evidence
Acceptability of suicide	No evidence	No evidence		-No evidence

Note. No evidence = 0 studies, Weak evidence = 1–2 studies, or more studies with contradictory evidence, Moderate evidence = 3–6 studies with minimal contradictory evidence, Strong evidence = More than 6 studies with minimal contradictory evidence.

Psychopathology

Psychological autopsy studies have found that up to 90% of those who take their own life were experiencing some form of psychopathology prior to their death (e.g., Cavanagh et al., 2003). Although other research methods produce rates closer to 50% (Yeh et al., 2019), psychopathology is still a leading risk factor for suicide. A meta-analysis found that many psychiatric diagnoses increase risk of suicide by at least 10-fold, including major depressive disorder (MDD), bipolar disorder, opioid use disorder, and schizophrenia compared with the general population (Chesney, 2014). Lower base-rates of bipolar disorder and schizophrenia make them less likely candidates to explain the higher rates of suicide in the Mountain West. However, roughly 60% of individuals who ended their life were found to have experienced a depressive illness in their lifetime (Lonnqvist, 2000), and substance use is implicated as a factor in approximately 38% of suicides (Cavanagh et al., 2003)—making them potential candidates for explaining the higher rates of suicide in the Mountain West.

Major Depressive Disorder (MDD)

A meta-analysis of psychological autopsy studies revealed that individuals who died by suicide were approximately nine times more likely to have had MDD than not (Conner et al., 2019). Although no studies have looked specifically at prevalence rates in the Mountain West, some epidemiological studies examined differences in prevalence of major psychiatric conditions across the four census regions of the country: the Northeast, Midwest, South, and West, which collapses the Mountain West and Pacific Coast. These data provide our best estimates of the rates of psychiatric conditions in the Mountain West.

The National Comorbidity Study (NCS; Kessler et al., 1994), the National Comorbidity Survey-Replication (NCS-R; Kessler et al., 2003), and the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; Hasin et al., 2018) all found no differences across regions in lifetime prevalence nor 12-month prevalence of any affective disorder. Although White adults were more likely to experience MDD than other races, men had lower odds of MDD than women, and individuals aged 65 and older had lower odds of MDD than younger age groups (Hasin et al., 2018). Importantly, additional findings by age from the NESARC suggest that the magnitude of the effect of a general psychopathology factor on suicide risk was significantly lower in individuals aged 50 and older (Pascal de Raykeer et al., 2018), suggesting that psychopathology like MDD may exert lower influence on suicide in older populations compared to younger age groups. Moreover, older White men have lower rates of depression but higher rates of suicide than older White women (Canetto, 2017). These findings reduce the likelihood that MDD is part of a cultural script for suicide among older White men in the Mountain West.

Substance Use

Alcohol and drug use are major risk factors for suicide (CDC, 2015), with a meta-analysis concluding that alcohol use was associated with a 94% increased chance of death by suicide (Isaacs et al., 2022). Notably, a meta-analysis summarizing 50 years of research contradicted this finding, reporting little effect of substance use disorders on suicide ideation, attempt, and death prediction (Franklin et al., 2017). However, a more recent meta-analysis of psychological autopsy studies revealed that individuals who died by suicide were approximately four times more likely to have had an alcohol use disorder and seven times more likely to have had a drug use disorder than non-suicide control groups (Conner et al., 2019). The National Comorbidity Study (NCS; Kessler et al., 1994) found that the West, along with the Northeast, had higher rates of DSM-III-R Substance Use Disorders compared to the Midwest and the South, though these differences were not replicated in analyses of 12-month prevalence rates. Moreover, men consistently report higher rates of substance use and substance use disorders than women (e.g., Lev-Ran et al., 2013). Potential regional differences in substance use disorders are reviewed below.

Alcohol and Alcohol Use Disorders.

Per capita alcohol consumption rates have been historically higher in the West than in other regions of the country (Dufour, 1998), raising the possibility that alcohol use and alcohol use disorders could be associated with elevated suicide rates in this region. States in the Mountain West continue to have higher per capita alcohol consumption than the rest of the country (with the notable exception of Utah, the home of the Church of the Latter-Day Saints, which forbids alcohol consumption), resulting in higher rates of death from alcoholic liver disease (Polednak, 2012). Results from the most recent National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III) revealed that the odds of alcohol use disorder were higher in the West than in the Northeast and the South (Grant et al., 2015). Moreover, results from the National Longitudinal Study of Adolescent Health found that the West had higher rates of alcohol abuse than the Northeast and higher rates of dependence than the Northeast, Midwest, and South (Haberstick et al., 2014). However, the evidence for heightened risk for alcohol use disorders among older, White men is less clear. Although men have higher prevalence of alcohol use disorders compared to women at all ages, very few men or women in epidemiological studies reported alcohol use disorders past age 75 (e.g., Vasilenko et al., 2017).

Drug Use and Drug Use Disorders.

The NCS found the highest rates of drug use in the West and Northeast and highest rates of drug dependence in the West (Warner et al., 1995). Similarly, the NESARC found that lifetime DSM-IV drug use and drug use disorder rates were higher in the West compared to all other regions of the country and 12-month prevalence rates of drug use disorders were higher in the West compared to South and Midwest (Compton et al., 2007). These findings were corroborated in the more recent iteration of the NESARC (i.e., 2012–2013, NESARC-III), which found both 12-month and lifetime drug use disorder rates were greater in the West (Grant et al., 2016), with individuals in the West having higher odds of 12-month and lifetime cannabis use disorders compared to those in the Midwest or South (Hasin et al., 2018). The West also has the highest rates of illicit drug use of any region in the U. S. among those 12 and older (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). Finally, a recent spatial analysis of drug poisoning deaths (e.g., prescription opioids, heroin), in the Western U.S. revealed multiple clusters of high-risk counties, including most of New Mexico, Nevada, Utah, and several counties in Arizona, Colorado, Idaho, and Wyoming (Kerry et al., 2019). Importantly, these high-risk clusters for drug poisoning death were positively correlated with suicide in these counties, suggesting a link between drug poisoning deaths and suicide—either directly (e.g., using prescription opioids as a method for suicide) or indirectly (e.g., substance use associated with interpersonal or occupational losses that may also represent a culturally recognized reason for suicide).

Although evidence suggests that drug use is substantially higher in the West compared to other regions, these studies do not provide data by race and age. Like alcohol use disorders, men across age groups were more likely to have a drug use disorder of any kind compared to women (Lev-Ran et al., 2013), suggesting evidence for an effect based on sex while obscuring effects of age and race.

Culture of Honor

States in the West (except for Alaska and Hawaii) and in the South have been classified as having a culture of honor (Nisbett & Cohen, 1996). In a culture of honor, reputation and self-worth are socially conferred and can be given, or taken, by others. By contrast, in cultures of dignity, found in the Midwestern and Northeastern U.S., self-worth is intrinsic and inalienable (Brown, 2016). To earn and defend one’s reputation in honor cultures, men are expected to be fearless, strong, and intolerant of disrespect (Brown, 2016; Nisbett & Cohen, 1996). Following cultural norms, including strict gender roles, is essential to maintain honor. Thus, men’s honor and self-worth are contingent on their success as protectors and breadwinners, but also include patriarchal attitudes, such as entitlement to dominate women (Brown et al., 2018; Cohen, 1996). Defending one’s reputation with physical aggression and violence if necessary is an expected male reaction to defend and restore honor (Brown, 2016).

Cultures of honor are found throughout the world, notably in frontier and herding cultures, where men historically needed to develop a reputation for aggression to deter thieves (Kitiyama et al., 2010). In the U.S., cultures of honor are found particularly in White (Nisbett & Cohen, 1996) and Latine communities (Gul et al., 2021). The U.S. male honor culture is associated with elevated rates of male suicide (Osterman & Brown, 2011), although this pattern is not universal. In Afghanistan, for example, women engage in protest suicide in response to the oppression and abuse they experience (e.g., Aziz, 2011). In the U. S., when older White men face barriers in fulfilling honor norms due to ageism, illness or disability, they may feel as though they are burdens to their family or feel alienated from those around them (Bock et al., 2019; Crowder & Kemmelmeier, 2017). Importantly, within cultures of honor, when men believe that an aspect of their honor (e.g., patriarchal entitlement, bravery, self-reliance) is challenged, suicide may be viewed as a viable response (Pridmore, 2009).

Firearms

Firearms were essential tools to the settlers of the American West. The region continues to have high levels of firearms ownership (Schell et al., 2020), which is associated with suicide rates (Miller et al., 2013). The states with the highest rates of suicide are also among those with the highest rates of firearms ownership. Using data from 1980–2016, Montana (66.3%), Wyoming (66.2%), Alaska, (64.5%) and Idaho (60.1%) were estimated to have the highest percentage of firearms ownership in the U.S. (Schell et al., 2020). Similarly, Wyoming, Alaska, Montana, Idaho, and New Mexico led the nation in 2020 in per capita death rates from suicides involving firearms (CDC, 2022a).

However, states in the southern region of the U.S. have higher rates of using firearms as a means of suicide than Western states. In examining the percentage of suicides involving firearms in 2020, the top 10 states include Mississippi (74%), Wyoming (73%), Alabama (67%), West Virginia (65%), Louisiana (65%), Kentucky (64%), Georgia (63%), Arkansas (62%), South Carolina (61%), and Montana (60%; CDC, 2022b). In reconciling these rankings with the above data on suicide death rates using firearms, it is important to note that the data on death rates involving firearms is heavily influenced by the overall suicide rates of the state. Thus, Southern states have lower overall rates of suicide than Western states, but those suicides are more likely to involve firearms.

Older White men who die by suicide in the U.S. are more likely to have used firearms than any other age/race/sex grouping (Martínez-Alés et al., 2021). Although firearms are an important component of suicides in the Mountain West, particularly for older White men, they are not unique to this region and may be part of a cultural script in the South as well. Of note, the West also has higher rates of non-firearms suicides than other regions of the country (Papadopoulos, et al., 2009).

Contextual factors

Suicide has been linked to broader economic and geographic factors, including low population density, economic factors, residential instability, low religiosity (e.g., Hirsch & Cukrowicz, 2014), and altitude (Kim et al., 2011). These contextual factors may provide a context for social isolation, one of the strongest predictors of suicide (e.g., Van Orden, et al., 2010), particularly for older men (Motillon-Toudic et al., 2022), and may be important for understanding suicide in the Mountain West.

Population Density

Large areas in the Mountain West have very low population densities, defined as the number of people per square mile (U.S. Census Bureau, 2022). Suicide rates have consistently been shown to be negatively correlated with population density (e.g., Hirsch & Cukrowicz, 2014). Decreasing population density is associated with more suicide deaths for nearly all demographic groups, including for men, Whites, and older adults (Ivey-Stephenson et al., 2017). One explanation for these findings is that lower population density may result in increased social isolation due to lack of available social opportunities. In support of this, compared to the rest of country, the Western U.S. has the strongest association between social isolation (i.e., unemployment and migration) and suicide in men (Trgovac et al., 2015).

However, population density may not be a direct contributor to suicide in this area. Rates of suicide are elevated in the Mountain West regardless of level of urbanization (Pepper, 2017). Moreover, a multivariate study of suicide in the West found that population density did not mediate the relations between a number of variables and high rates of suicide in Western states compared to Eastern states (Barkan et al., 2013). Overall, current data suggest that low population density is not sufficient to explain the higher rates of suicide in the region.

Economic Factors

The economic industries of mining, quarrying, and oil and gas extraction have the highest suicide rate in the U.S. (Peterson et al., 2020). These industries, where White male employees are overrepresented (McWilliams et al., 2012), have historically dominated the economy of the Mountain West (Shumway & Otterstrom, 2001) In 2013, Wyoming, Alaska, New Mexico, and Montana were among the top ten states with the highest proportion of their GDP in mining and extraction, with Wyoming and Alaska topping the list (Morris, 2016). Interestingly, these were also the four states with the highest suicide rates (AFSP, 2022). Economic reliance on the mining industry in these states could contribute to increased suicide rates, especially for White men (although women in these industries also experience an increased suicide rate; Peterson et al., 2020).

The mechanisms by which the mining and extraction industries increase rates of suicide may be indirect (e.g., through increased financial stress, separation from social supports, and residential instability). Mining is an unstable boom-and-bust industry linked to the cyclical migration pattern of the Mountain West, with periods of rapid growth followed by much slower expansion (Otterstrom & Shumway, 2003). Increases in depression and anxiety from bust cycles of the mining industry (Shandro et al., 2011) could lead to elevated suicidality in the region through community-level economic and individual-level financial stress. Evidence suggests older adults are particularly at risk for contemplating and attempting suicide after experiencing such status loss (defined as decline in socioeconomic status; Dombrovski et al., 2018). Moreover, employment instability of the extraction industries contributes to low residential stability in the region as individuals move in search of new or more stable employment.

Residential Stability

Residential stability, the percentage of the population that has not recently changed residences, is another predictor of regional suicide rates (Baller & Richardson, 2002; Barkan et al., 2013). The Mountain West has the lowest rates of residential stability in the U.S., with consistent increases in population from 1910 through 2020 (U. S. Census Bureau, 2021). In addition to the stressors associated with relocating for those who move, living in a mobile community is stressful for residents who remain, as they face the loss of important relationships (Talhelm & Oishi, 2014). Low residential stability erodes social integration as residents are less invested and less connected with their community. For example, communities with less residential stability are more likely to be “fair weather fans” of home baseball teams with decreased support following a loss. More stable communities, in contrast, supported their teams regardless of win-loss records, and even increased attendance when the team had a losing record (Oishi et al., 2007).

Low residential stability in the Mountain West may lead to reduced levels of social connection in these communities and could be a contributing factor in elevated suicide rates. Two of the few studies to directly examine suicide in the Western U.S. concluded that low residential stability, directly contributes to elevated rates of suicide in this region (Baller & Richardson, 2002; Barkan et al.,2013), possibly explained by residents moving in and out of the area to pursue economic opportunities and recreational activities (Shumway & Otterstrom, 2001). However, no studies have specifically examined residential stability in White men within the Mountain West.

Religion

Higher levels of religious involvement are typically associated with reduced risk of suicide (Stack, 2000) and lower levels of suicide acceptability (Winterrowd et al., 2017), although in some circumstances, religion may be more helpful for men than for women. For example, in China, involvement in Confucianism is protective for men, but increases suicide risk for women (Zhang et al., 2014). Many religions, including those prominent in the Mountain West, designate suicide as an immoral or sinful act. Adopting this view is associated with lower suicide ideation and reduced history of suicide attempts (e.g., Jongkind et al., 2019). These messages operate through both the religious convictions of individuals and community norms that lower the acceptability of suicide.

The Mountain West has lower rates of religious affiliation relative to the rest of the nation (Nugent, 2004). Apart from Utah and Idaho, which have high membership in The Church of Jesus Christ of Latter-Day Saints, most people in the region are unaffiliated with religion. Studies of the U.S. regional pattern of suicide cite the West’s relatively lower levels of religious integration as an important reason for its higher suicide rate (Baller & Richardson 2002). One potential mechanism for lower suicide rates is that religious participation often includes increased social interaction and connection. Some evidence suggests that the relationship between religiosity and low suicide rates is accounted for by the social support that comes from religious communities (Robins & Fiske, 2009). Among members belonging to varying religious communities, higher sense of community was associated with increased belongingness and reduced suicidal ideation (Mason, et al., 2018). Thus, the low levels of religiosity in the West could contribute to lacking a sense of community and feelings of isolation described above, thereby increasing suicidal ideation.

Alternatively, a moral communities perspective posits that in countries with high religiosity, individuals endorse lower levels of acceptability of suicide, regardless of their own religious beliefs (Stack & Kposowa, 2016). Furthermore, individuals who are more socially isolated and not attending religious services are more likely to find suicide acceptable (Phillips & Luth, 2020). Thus, low levels of religious affiliation in the Mountain West could also suggest high acceptability of suicide.

Altitude

Altitude presents an intriguing variable in explaining the high rates of suicide in the Mountain West. While controlling for numerous psychosocial covariates, the correlations between altitude and suicides are strikingly large (r = .70) in both the United States (Ha & Tu, 2018; Kim et al., 2011; Kim et al. 2014) and South Korea (Kim et al., 2014). Various biophysiological models have been proposed to explain this finding, including hypoxia, which directly impacts neurotransmitters in the brain (Kim et al., 2011), drug pharmacokinetics, and/or cellular metabolism (Arancibia et al., 2003; Prescot, 2021), resulting in depression or impulsivity. However, evidence for a specific mechanism is weak and individual and cultural factors likely still contribute to suicide risk (Reno et al., 2018; Ha & Tu, 2018). Importantly, Shrira and Christenfeld (2010) found that both visitors to and residents traveling away from states in the Mountain West had elevated suicide rates—to the same extent as residents dying from suicide inside the region. Ultimately, these findings suggest that contextual features of the Mountain West region likely contribute to suicide deaths among White men who live in the region.

Areas needing further research

Explanations for high rates of suicides in the Mountain West often cite stigma associated with mental health and treatment and regional norms of suicide acceptability. Although we could find no data examining regional differences in these attitudes, they could be important mechanisms in a cultural script for suicide for White men in this region.

Stigma associated with mental health and mental health treatment

Attitudes about mental health, particularly stigma associated with mental illness, help seeking, and help seeking for mental illness, could all contribute to suicide in the Mountain West. Although we could find no studies in this region, studies of attitudes in regions with different rates of suicide may provide useful models. For example, citizens of Flanders, where suicide rates are high, had more negative attitudes toward help seeking and more self-stigma than citizens in the Netherlands, where rates were lower. These attitudes predicted help-seeking intentions and behavior (Reynders et al., 2014). However, in a study of regional attitudes of men in Quebec, attitudes about help seeking and the acceptability of suicide did not correlate with regional differences in suicide rates (Desaulniers & Daigle, 2008). Until we have regional data on mental health and treatment stigmas in the U.S., it is unclear which pattern will best describe White men in the Mountain West.

Acceptability of Suicide

Two studies conducted in the Mountain West found that suicide among older men was viewed as acceptable in the context of physical disability or interpersonal loss (Stice et al., 2008; Winterrowd et al., 2017). High suicide acceptability within an area has been linked to higher suicide rates in that region compared to regions with lower acceptability (Kleiman, 2015). Similarly, at the level of individual attitudes, endorsing the belief that suicide is acceptable was found to be the best prospective predictor of later suicide (Feigelman et al., 2004), and specifically predicts suicides in individuals older than 55 (Phillips & Luth, 2018). Exposure to suicide, whether through experiencing a personal loss or hearing about a suicide, may alter attitudes, making suicide a more acceptable solution to hardships.

In suicide contagion, exposure to suicide is linked to increased suicide risk and deaths by suicide, leading to localized suicide point clusters in schools and communities following an initial suicide. These clusters are generally thought of as imitation suicides, operating through a mechanism of imitation (Cheng et al., 2014; Haw et al, 2013), occurring in a similar time or space (Gould et al., 1989), and generally limited to adolescents (Kleiman, 2015). Others argue that suicide clusters are not caused by imitation, but by clustering of societal variables that lead to suicide (Haw et al., 2013). A spatial analysis found evidence that areas with high suicide rates in the American West also had high clustering of variables related to social integration. Additionally, they found no evidence of imitation, where suicides would follow suicides in the same area (Baller & Richardson, 2002).

Alternatively, suicides could alter the context of future suicides by changing group norms. Under this model, individuals do not need to be directly exposed to information about a specific suicide to experience increased risk (Cheng et al., 2014). A study in Sweden, for example, found clustering of middle-aged and older White men living in rural areas who used firearms to end their lives (Chotai, 2005). Although this form of suicide contagion appears consistent with stable elevated rates of suicide in older White men in the Mountain West, data on attitudes across regions are needed to clarify the nature of these clusters.

A Cultural Script for Suicide in the Mountain West

In this article we reviewed proposed risk factors that may explain the high rate of suicides in the Mountain West region. Using this information, we next describe a cultural script for suicide following Canetto’s cultural script theory (Canetto, 1997, 2017, 2021) for older White men in this region that provides a culturally sanctioned explanation of why individuals die by suicide. Research into a suicide script in the Mountain West region revealed that for older White men, experiencing physical illness was the most acceptable precipitant to suicide, followed by the death of a close relative (Stice et al., 2008; Winterrowd et al., 2017). Older men themselves were the most likely to view suicide in the context of illness to be acceptable, rational, and even courageous (Winterrowd et al., 2017). Thus, suicide may be seen as a reasonable, and even a moral response to physical illness or social isolation by the wider community (Stice et al., 2008; Winterrowd et al., 2017) and particularly for older men themselves (Winterrowd et al., 2017).

In addition, exposure to suicide at the community level may increase risk for suicide (Pitman et al., 2014) by creating a script that includes high rates of suicide among older men as a cultural expectation. The high rates of suicide in older White males in the Mountain West may be evidence of the acceptability of this behavior, which in turn may enable these men to act in accordance with this norm (Canetto, 2017). Among White Americans, suicide itself is viewed as a masculine behavior, and for older White men, a courageous act of self-determination (Canetto, 1997). High rates of firearms ownership in the Mountain West, also valued as a masculine behavior (Canetto & Sakinofsky, 1995), increases the access to a particularly lethal means of suicide (Brown et al., 2014b). Thus, suicide by firearms is viewed as a particularly masculine solution to difficult life circumstances for older, White men.

Building upon this research, the current review identified novel regional contextual factors that may contribute to the culturally sanctioned explanation for suicide among older White, including factors that increase social isolation. The economic volatility in the Mountain West results in job losses in fields dominated by White men (Otterstrom & Shumway, 2003), leaving older White men unable to fulfill expected roles in their families and communities (Crowder & Kemmelmeier, 2017). Moreover, unemployment leads to high residential instability (U. S. Census Bureau, 2021), with both factors converging to predict suicides in men in the Mountain West (Trgovac et al., 2015), as residents move in and out of communities in search of work without making lasting connections. Similarly, low levels of religiosity in the region reduce one possible source of social connection. Taken together, these contextual factors increase the likelihood of social isolation in the region.

Canetto’s cultural script theory defines the values and expectations of the larger community (Canetto, 1997, 2017, 2021). Our review, however, also suggests pathways for explaining individual level behavior within the context of this cultural script. The Interpersonal Theory of Suicide (IPTS; Joiner, 2005; Van Orden et al, 2010) provides a framework to consider how the culture of the Mountain West may influence individual suicidal desire and attempts. Although this theory has been highly influential in the study of suicide, authors have raised critiques regarding the arguments and evidence for IPTS, including that it ignores the larger context(s) within which suicidality develops and is maintained (e.g., Hjelmeland et al., 2020). Importantly, situating regionally specific factors associated with suicides in a specific population according to a cultural script framework may provide such context for the risk factors proposed by IPTS. Accordingly, IPTS proposes that suicidal desire is driven by thwarted belongingness and perceived burdensomeness. Given the results of the current review, we propose that IPTS constructs can be integrated with culture of honor to provide a framework for understanding suicidal behavior in older White men in the Mountain West, as loss of honor may lead to both thwarted belongingness and perceived burdensomeness and contribute to acquired capability for suicide (Bock et al., 2019, 2021).

For older White men, being unable to fulfill masculine duties to provide for and protect their family prescribed in a culture of honor leads to feelings of perceived burdensomeness in the face of health complications that impair their ability to fulfill this obligation (Crowder and Kemmelmeier, 2017). The resulting loss of social reputation, tied to self-worth in a culture of honor, also creates a feeling of thwarted belongingness (Bock et al., 2019; Crowder & Kemmelmeier, 2017). Thus, multiple experiences of aging, including ageism, retirement, job loss, or loss of mobility from illness or disability, that inhibit fulfilling the masculine roles of protectors and providers may lead to perceived burdensomeness and thwarted belongingness in a culture of honor, thereby increasing suicidal desire (Crowder & Kemmelmeier, 2017).

A final component for serious suicide attempts, according to IPTS, acquired capability for suicide, was originally conceptualized through increased pain tolerance and reduced fearlessness about death gained with experiencing painful and provocative events. For example, hunting and ranching activities in the Mountain West bring exposure to death, thereby building habituation to fear of death. More recently acquired capability for suicide has been expanded to include practical capability, including knowledge and skills needed to kill oneself (Bryan, 2016). Bock and colleagues (2021) argue that for men, culture of honor beliefs lead to masculine behaviors that are associated with a history of painful and provocative events, including risky behaviors and violence in the service of protecting one’s honor, as well as honor-related preparations for future violence. These experiences create practical capability for suicide, including firearms ownership and specific knowledge, such as how to use firearms. This may explain why cultures of honor in the U.S. are associated with high rates of firearm ownership for White men (Bock et al., 2019), who are more likely to die by suicide, and are more likely to use firearms as the means for suicide (Brown et al., 2014b). Moreover, when masculine norms dictate that failures and humiliations are a cause of shame, suicide may be viewed as a viable response (Pridmore, 2009), and the pressure on men not to survive their suicidal act may be a particularly powerful incentive for firearm usage (Brown et al., 2014b). This also explains why men’s suicide attempts are more lethal than women’s across all methods (McAndrew & Garrison, 2007).

High rates of substance use in the Mountain West could also be a factor in the script for suicide, operating through acquired capability for suicide. The pressure to convey masculine toughness by suppressing distress may lead to substance use as a socially acceptable way to escape negative emotions while also reducing psychological barriers and increasing practical capability for suicide. In addition, alcohol intoxication during suicide is associated with the use of firearms in adults over age 50, possibly by reducing the inhibition for using more violent means (Choi et al., 2018).

Finally, endorsement of culture of honor beliefs is associated with reluctance to seek help for fear of damaging one’s reputation, further exacerbating feelings of shame and burdensomeness, particularly in younger men (Brown et al., 2014a). Thus, White men in honor cultures experiencing emotional difficulties or psychopathology may also be less likely to request advice from others or seek mental health treatment due to their rigid norms of masculinity, thereby raising suicide risk.

Of note, masculinity norms that are not tied to cultures of honor are also associated with suicide deaths (Coleman et al., 2020). Within U.S. cultures of honor, masculinity norms are based on managing and defending one’s reputation, but these are likely similar to masculinity norms that are not based in cultures of honor, sharing common expectations of behavior such as toughness and self-reliance (Bock et al., 2021). A separate literature found that non-honor-based masculinity norms are also associated with avoidance of help-seeking behaviors for suicide (McDermott et al., 2018). For individuals who develop perceptions that options to escape distress are limited—perhaps through masculinity-based stigma associated with mental illness and treatment and fears about sharing weaknesses—suicide becomes an increasingly viable option (Cleary, 2012), particularly in a culture that normalizes suicide and defines it as an act of masculinity (Canetto, 1997).

Interventions

Suicide prevention efforts have been developed that target men (Struszczyk et al., 2019). An initial challenge is getting men to seek mental health services. “Man Therapy,” an online suicide prevention initiative, was found to increase professional help seeking in men (Gilgoff et al., 2023). Next, intervention services must be appropriate and appealing to men. A qualitative study of older White men’s views of suicide concluded that psychotherapy interventions should emphasize men’s desire to have purpose and feel useful and foster more flexible views of masculinity, such as pursuing emotionally supportive relationships to reduce suicide in older White men (King, 2020).

Similarly, increasing caregiving in men may be a pathway to reduce suicides. By defining their worth in terms of public-life behaviors, such as employment, Canetto (2017) argues that men underinvest in caring for others. Women typically continue to care for family, and this fulfilling role may explain why their suicide rates decline in old age. Suicide rates are lower in countries where men report doing more family caregiving, and higher unemployment rates were not associated with suicide for men in these countries, suggesting that caregiving buffers the effects of job loss (Chen et al., 2021). Policy changes that increase family caregiving in men (Barker, 2014) could diversify sources of meaning and fulfillment for men and expand their social networks, thereby reducing suicide risk.

Summary and Conclusions

Building on Canetto’s work on cultural scripts of U. S. White male suicide (e.g., Canetto, 2017), this review generated a complex—and likely incomplete—picture of the suicide scripts of older White men in the Mountain West Region of the United States. The suicide script in the Mountain West specifies older White men as the most suicide vulnerable group. Loss of ability to fulfill norms of masculine roles and accompanying shame, as well social isolation, may be understood as motives following physical illness or disability. Job loss, or other defeat or loss of status stemming from regional economic hardships and occupational instability may also be precipitants to suicide (Dombrovski et al., 2018). Social isolation in the absence of stabilizing forces of residential stability and religion may be understood by the community to be valid precipitants for suicide for older White men. The pressures on men to demonstrate dominance and toughness even pervades the act of suicide itself, as using a firearm as a method of death by suicide is seen as a noble act of strength whereas a survivable attempt may be viewed as failure and weakness (Canetto, 1997, 2017). The community response to the suicide may be shrugged off as an expected, and even courageous act (Stice et al., 2008) in face of disability, subsequent burdensomeness, and loss of honor, thereby contributing to the script that normalizes suicide for older White men.

Limitations

Relatively few studies have examined regional differences in suicide rates, and among those that do, some collapse the Mountain West and the Pacific West. Low suicide rates and cultural differences in states like California and Hawaii in the Pacific West may mask findings in this broader region. Similarly, it is unlikely that the Mountain West area as defined by state borders neatly divide higher and lower suicide areas. Furthermore, within this broad region it is likely that there are sub-regions defined by other cultural factors that are associated with unique suicide predictors. Areas of Utah and Idaho that have high populations of members of the Church of the Latter-Day Saints and areas of New Mexico, Arizona, Colorado, and New Mexico with large populations of Latine individuals and Indigenous Peoples could show different patterns of predictors of suicide. Wyoming, Montana, and Alaska consistently have the highest rates of suicide in the nation and may represent the true “suicide belt” of the U.S.

Much of the attention on suicides in the Mountain West has focused on White men, as they account for the highest number of deaths. However, women in the Mountain West also have the highest rates of suicide in the United States, although the numbers are a fraction of those for men (Pepper, 2017). The risk factors that account for elevated suicide rates in men may be similar for women in this region, although there may be specific differences in cultural scripts for women. Likewise, most of the literature on suicide in the Mountain West focuses on White European settlers, often erasing the existence of the Indigenous Peoples and early Spanish settlers and their descendants. Importantly, Indigenous peoples have the highest rates of suicide within the region, with higher rates compared to Indigenous peoples in other parts of the country. It is likely that the cultural factors associated with forced removal from ancestral lands, hardships of reservations, and unique cultures of the nations in this region are important factors in a cultural script that may explain why Indigenous Peoples in this region are more likely to die by suicide (Wexler & Gone, 2012).

Finally, although we have framed this review around individual risk factors, most studies have examined multivariate models to explain regional differences in suicide, offering us a clearer picture of cultural scripts for suicide. Thus, it is likely that relationships among these risk factors are more complex than represented and have additional correlates not explored here.

Future Directions

Although the current review elucidated several potential risk factors that may be responsible for high rates of suicide in the Mountain West, it also revealed a paucity of research that aims to examine regional differences in suicide in the United States. More research is needed to clarify regional variations in risk factors for suicide, separating effects by sex, race, and age, to better understand specific cultural scripts for suicide. Multivariate analyses and spatial mapping analyses should be used to explore the complexities of the constructs that contribute to the cultural script of suicide risk in the Mountain West. The risk factors reviewed in the present article may be a place to start in terms of mapping clusters of risk and resilience for suicide in the United States.

Public Significance Statement.

Based on a review of the research on elevated suicide rates in the Mountain West, we propose a cultural script for suicide that describes who dies by suicide, how people in this region may view suicide, when it is considered acceptable, and what meanings are communicated through the act of suicide. This proposed cultural script could guide future research and policy to reduce suicides in this region.