Social Science & Medicine 57 (2003) 1183–1194 Urban–rural differences in suicide trends in young adults: England and Wales, 1981–1998 Nicos Middleton a , David Gunnell a, *, Stephen Frankel a , Elise Whitley a , Daniel Dorling b a Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK b School of Geography, University of Leeds, Leeds LS2 9JT, UK Abstract Suicide rates amongst young people, particularly males, have increased in many industrialised countries since the 1960s. There is evidence from some countries that the steepest rises have occurred in rural areas. We have investigated whether similar geographical differences in trends in suicide exist in England and Wales by examining patterns of suicide between 1981 and 1998 in relation to rurality. We used two complementary population-based indices of rurality: (1) population density and (2) population potential (a measure of geographic remoteness from large concentrations of population). We used the electoral ward (n ¼ 9264; median population aged 15–44: 1829) as the unit of analysis. To assess whether social and economic factors underlie rural–urban differences in trends we used negative binomial regression models to investigate changes in suicide rates between the years for which detailed national census data were available (1981 and 1991). Over the years studied, the most unfavourable trends in suicide in 15–44-year olds generally occurred in areas remote from the main centres of population; this effect was most marked in 15–24-year-old females. Observed patterns were not explained by changes in age- and sex-specific unemployment, socio-economic deprivation or social fragmentation. The mental health of young adults or other factors influencing suicide risk may have deteriorated more in rural than urban areas in recent years. Explanations for these trends require further investigation. r 2003 Elsevier Ltd. All rights reserved. Keywords: Suicide; Mental health; Social fragmentation; Urban–rural differences; England and Wales Introduction Youth suicide, especially young male suicide, has increased in many industrialised countries in the last 40 years (Charlton, Kelly, Dunnell, Evans, & Jenkins, 1993; Cantor, 2000). In England and Wales, suicide rates have declined in females and older (>45 years) males since the 1960s (Charlton et al., 1993). In contrast, young male suicide rates have doubled and in 1999 25–34-year- old males had the highest rate of all age and sex groups including the elderly (Gunnell, Middleton, Whitley, Frankel, & Dorling, 2002; Middleton & Gunnell, 2000). Research in Australia (Dudley et al., 1997, 1998b; Dudley, Kelk, Florio, Howard, & Waters, 1998a) and Norway (Mehlum, Hutten, & Gjersten, 1999) shows that the steepest rises in suicide in young adults since the 1960s/1970s have occurred in rural areas. It is speculated that the increases in Australia may be due to declines in the rural economy and subsequent break-up of family units and/or the migration of healthier individuals away from rural areas leaving behind a greater concentration of more susceptible individuals (Dudley et al., 1997). In England and Wales, cross-sectional studies show that while suicide rates tend to be high in urban areas in both sexes, high rates are also found amongst males living in rural and resort areas (Kelly, Charlton, & Jenkins, 1995; Saunderson & Langford, 1996). No previous study has investigated rural–urban differences ARTICLE IN PRESS *Corresponding author. Tel.: +44-117-928-7253; fax: +44- 117-928-7236. E-mail address: d.j.gunnell@bristol.ac.uk (D. Gunnell). 0277-9536/03/$-see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0277-9536(02)00496-3