Suicide Mortality: A Comparison of Urban and Rural Rates

Suicide contributes to significant mortality in the United States, accounting for over 48,000 deaths in 2021 alone. There are multiple risk factors for suicide, including age, access to mental health care, geographic isolation, stigma, at-risk substance use, access to firearms, and other social factors. Many of these factors disproportionately affect people living in rural areas.

This project examined the differences in suicide rates by geography and explored its driving factors among urban and rural areas in the United States from 2018 to 2021. The research design of this study adopted a cross-sectional, retrospective approach, using secondary data.

Data from the National Vital Statistics System (NVSS) maintained by the Centers for Disease Control and Prevention (CDC) were used for this project. Age-adjusted suicide mortality data from multiple-causes-of-death mortality files for years 2018-2021, with the underlying cause-of-death codes were used to define suicide. These data were combined with other publicly available data sources for county-level sociodemographic, economic, health care characteristics, and health indices.

For county-level analysis, we aggregated suicide rates from 2018-2021 and explored the spatial distribution across the U.S., and then compared these rates with demographic characteristics using multivariable linear and logistic regression. We also planned to explore the utility of integrating an area-level measure of social vulnerability as part of the multivariable analyses. To further understand the spatial patterns and distribution, we conducted spatial analyses such as hotspot analysis and bivariate mapping among counties in the U.S.

At the state level, we analyzed suicide rates per year (2018, 2019, 2020, and 2021) and by rurality (Rural-Urban Continuum Codes) using bivariate analyses. This was followed by multivariable analyses that control for county-level characteristics. Similarly, we compared these rates with demographic characteristics and examined the feasibility of incorporating an area-level measure of social vulnerability. These analyses used multivariable linear and logistic regression and spatial regression.

Findings from this study were of interest to policymakers, practitioners, researchers, and community leaders. Such applications of findings from this study will predominantly affect vulnerable communities with large rural residents.

Publications

• Rural and Urban Differences in Suicide in the United States, 2018-2021
  Policy Brief
  ETSU/NORC Rural Health Research Center
  Date: 05/2025
  Suicide remains a significant cause of mortality in the United States. This policy brief examines state-level differences in suicide rates by demographics and geography, with a focus on rural and urban areas from 2018 to 2021. The study employs a cross-sectional, retrospective design using secondary data sources.