Objective: Previous research indicates a potential relationship between rurality and suicide, indicating that those living in rural areas may be at increased risk of suicide. This relationship has not been reviewed systematically. This study aims to determine whether those living in rural areas are more likely to complete or attempt suicide. Method: This systematic review and meta-analysis included observational studies based on people living in Canada, the United States, the United Kingdom, and Australia. Data sources included PubMed, EMBASE, PsycINFO, and Google Scholar from January 2006 to December 2017. Studies must have compared rural and urban suicide or suicide attempts. Nonprimary research articles were excluded. Results: A total of 6,259 studies were identified and 53 were included. Results indicate that males living in rural areas are more likely to complete suicide than their urban counterparts (RR = 1.41, 95% CI, 1.21 to 1.64, I 2 = 96%). Females in rural areas are not significantly more likely to complete suicide (RR = 1.16, 95% CI, 0.98 to 1.37, I 2 = 79%). Among studies that only reported combined estimates, rural individuals are more likely to complete suicide (RR = 1.22, 95% CI, 1.11 to 1.33, I 2 = 98%). There is no association found between rurality and suicide attempts (RR = 0.93, 95% CI, 0.73 to 1.19, I 2 = 85%). Conclusions: Those living in rural areas are more likely to complete suicide, with some studies indicating that only rural males are more likely to complete suicide; these findings are relatively consistent across all four countries. Public health initiatives should aim to overcome geographic variation in completed suicide, with a particular focus on rural males.

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Objective This study aims to examine rural and urban differences in attempted suicide and death by suicide in Ontario, Canada. Method This is a population-based nested case-control study. Data were obtained from administrative databases held at ICES, which capture all hospital and emergency department visits across Ontario between 2007 and 2017. All adults living in Ontario who attempted suicide or died by suicide are included in the study, and controls were matched by sex and age. Suicides were captured using vital statistics. Suicide attempts were determined using emergency department service codes. Results Rurality is a risk factor for attempted suicide and death by suicide. Rural males are more likely to die by suicide compared with urban males (adjusted odds ratio(AOR) = 1.70, 95% confidence interval (CI), 1.49 to 1.95), and the odds of death by suicide increase with increasing levels of rurality. Rural males and females have an increased risk of attempted suicide compared with their urban counterparts (males: AOR = 1.37, 95% CI, 1.24 to 1.50) (females: AOR = 1.26, 95% CI,  1.14 to 1.39), with a pattern of increasing risk of suicide attempts with increasing rurality. Rural females are not at increased risk of suicide compared with urban females (AOR = 1.08, 95% CI, 0.80 to 1.45). Sensitivity analyses corroborated the results. Conclusions Rural males are almost two times more likely to die by suicide compared with urban males, and both rural males and females have an elevated risk of suicide attempts compared with urban residents. Future research should examine potential mediators of the relationship between rurality and suicide.