What you need to know
People who live in rural areas have a higher risk of dying by suicide than those who live in urban areas. However, Canadian research on this topic has found conflicting evidence. There is also a lack of research on the relationship between rural living and suicide attempts. Researchers conducted a study using a large population-based database to examine whether there is a difference between rural and urban suicides and suicide attempts. They found that males living in rural areas are almost two times more likely to die by suicide compared with those living in cities. In addition, rural males and females are at greater risk of suicide attempts compared with their urban counterparts.
What is this research about?
Previous research from United States, China and Australia has shown that people living in rural areas are at greater risk of suicide than those living in cities. However, Canadian research has found conflicting results, with some studies showing an association and others showing no association. There is also limited research on the risk of suicide attempts among people living in urban and rural areas. The only studies on suicide attempts in Canada have looked at seniors living in nursing homes and adolescents.
Researchers analyzed data from a large database of population data to examine deaths by suicide and suicide attempts to determine whether disparities exist among Ontario residents living in rural and urban areas.
What did the researchers do?
The researchers used data from administrative databases and a nested, matched, case-control design. This type of study involves analyzing data on several healthy controls for each case. In this study, there were four controls for every person who died by suicide and two controls for every case of attempted suicide.
The cases of suicide were adults (ages 18 or more) living in Ontario who died by suicide between April 1, 2007 and December 31, 2015. The controls were matched for age and sex with the cases and were alive at the time of the matched case’s death by suicide.
Cases of attempted suicide were adults who attempted suicide between April 1, 2007 and March 31, 2016. The researchers only used the first suicide attempt observed in the previous year. Controls were matched for age and sex and had not previously attempted suicide at the time of the case’s attempt.
What did the researchers find?
The risks of attempting suicide were higher for both men and women living in rural areas compared to those living in urban areas. The risk of dying by suicide was higher for males living in rural areas compared to those living in urban areas. The risk of both dying by suicide and attempting suicide increased as the location became more remote. People who died by suicide or attempted suicide were more likely to be born in Canada and were more likely to live in neighbourhoods that had more residents who were lower income and had unstable housing.
The relationship between death by suicide and suicide attempts become more likely with increasing levels of rurality. There were also specific findings for death by suicide and attempted suicide.
Death by suicide
Males made up almost three quarters (73 percent) of the 9,848 people who died by suicide. Males living in the most rural areas were 70 percent more likely to die by suicide.
Females who lived in rural areas were not more likely to die by suicide than females living in cities.
People who died by suicide were more likely to have a prior suicide attempt.
Attempted suicide
Both males and females who lived in rural areas were significantly more likely to attempt suicide than those living in cities. The risk increased when the location became more remote. This was especially the case for males, who were up to 75 percent more likely to attempt suicide, while for the most rural females, this risk was up to 45 percent greater than those living in cities. Females made up slightly more than half (52 percent) of the 82,180 people who attempted suicide.
Limitations of the research
The researchers identified various limitations of using population-level administrative data. In particular, the data did not allow them to analyze the influence that factors such as stigma, health beliefs and attitudes towards help seeking might have on the relationship between rurality and suicide.
The study also did not include data on Indigenous status or lesbian, gay, bisexual, transgender and queer (LGBTQ) status. This is important because these populations are at greater risk of suicide attempts and death by suicide than the general population and experience more barriers to healthcare, according to previous research.
Another study limitation is that some suicides may have been recorded as accidental. Those in rural areas are more likely to use firearms to end their life, while those in more urban areas are more likely to use drugs, both of which may be more likely to be considered an accidental death.
How can you use this research?
This study may be of interest to policymakers and program planners looking to implement interventions to reduce suicide attempts and deaths by suicide. The authors suggest potential interventions, such as increasing access to telephone- and internet-based mental health care services, community-based approaches, as well as mental health and suicide training for general practitioners in rural areas.
The authors also point to the need for approaches to address the high rates of suicide and suicide attempts among men living in rural areas. In addition, they point to the need for policy changes to ensure there is adequate access to high-speed internet in rural areas.
About the researchers
Rebecca Barry1, Jürgen Rehm1,2,3, Claire de Oliveira1,2,4, Peter Gozdyra5, Simon Chen5 and Paul Kurdyak1,2,5
- University of Toronto, Toronto, Ontario
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Dresden University of Technology, Dresden, Germany
- Centre for Health Economics and Hull York Medical School, University of York, York, United Kingdom
- ICES, Toronto, Ontario, Canada