• Paul S Nestadt, Patrick Triplett, David R Fowler, and Ramin Mojtabai.
• Paul S. Nestadt and Ramin Mojtabai are with the Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Patrick Triplett is with the Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore. David R. Fowler is with the Office of the Chief Medical Examiner, Baltimore.
• Am J Public Health. 2017 Oct 1; 107 (10): 1548-1553.

ObjectivesTo assess whether the use of firearms explains rural-urban differences in suicide rates.MethodsWe performed a retrospective analysis on all 6196 well-characterized adult suicides in Maryland from 2003 through 2015. We computed rate ratios by using census data and then stratified by sex, with adjustment for age and race.ResultsSuicide rates were higher in rural compared with urban counties. However, the higher rural suicide rates were limited to firearm suicides (incident rate ratio [IRR] = 1.66; 95% confidence interval [CI] = 1.20, 2.31). Nonfirearm suicide rates were not significantly higher in rural settings. Furthermore, 89% of firearm suicides occurred in men and the higher rural firearm suicide rate was limited to men (IRR = 1.36; 95% CI = 1.09, 1.69). Women were significantly less likely to complete suicide in rural areas (IRR = 0.63; 95% CI = 0.43, 0.94), regardless of method.ConclusionsMale firearm use drives the increased rate of suicide in rural areas. The opposite associations between urbanicity and suicide in men and women may be driven by the male preference for firearms as a method for committing suicide.

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