Rural-Urban Differences in Suicide and Firearm-Related Suicide Deaths Across Geographic Regions in the U.S.

Abstract

This study assessed differences in overall suicide and firearm-related suicide rates across urban and rural U.S. counties and explores variation by geographic region. An ecologic cross-sectional analysis was conducted using generalized linear models with a negative binomial distribution and log link to estimate incidence rate differences, incidence rate ratios with 95% CIs, and the proportion of suicide deaths attributed to firearms across rural and urban U.S. counties, overall and by Census region. Data were obtained from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research database (2015-2020) and analyzed between 2023 and 2025. Between 2015 and 2020, there were 274,973 suicides, with 137,051 (49.7%) involving firearms. Suicide and firearm-related suicide rates increased with rurality, peaking in the most rural counties (31.2 and 24.5 per 100,000), although linear trends across the Rural-Urban Continuum Codes were not significant (overall p_trend=0.053; firearm-related p_trend=0.115). Rural counties had higher suicide rates than urban counties (overall: incidence rate difference=3.4, incidence rate ratio=1.21, 95% CI=1.18, 1.25; firearm related: incidence rate difference=3.4, incidence rate ratio=1.37, 95% CI=1.33, 1.42), with the largest disparities in the West and the smallest in the South (all p_int<0.0001). The proportion of suicides involving firearms increased with rurality overall (p_trend<0.0001), with the magnitude of rural-urban differences varying across geographic regions (p_int<0.0001). Results demonstrate rural-urban disparities in suicide and firearm-related suicide rates, with variation in magnitude across U.S. geographic regions. These findings underscore the need for regionally tailored suicide prevention efforts in rural areas with higher firearm access and limited mental health services.