Open Access Highly Accessed Research article

Contributors to suicidality in rural communities: beyond the effects of depression

Tonelle E Handley1*, Kerry J Inder12, Frances J Kay-Lambkin13, Helen J Stain146, Michael Fitzgerald2, Terry J Lewin126, John R Attia257 and Brian J Kelly14

Author Affiliations

1 Priority Research Centre for Translational Neuroscience and Mental Health, University of Newcastle, Newcastle, Australia

2 Hunter Medical Research Institute, Locked Bag 1, Hunter Region Mail Centre, Newcastle, Australia

3 National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia

4 Centre for Rural and Remote Mental Health, University of Newcastle, Orange, NSW, Australia

5 Centre for Clinical Epidemiology and Biostatistics, University of Newcastle, Newcastle, Australia

6 Schizophrenia Research Institute, Sydney, Australia

7 Department of Medicine, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, Australia

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BMC Psychiatry 2012, 12:105  doi:10.1186/1471-244X-12-105

Published: 8 August 2012



Rural populations experience a higher suicide rate than urban areas despite their comparable prevalence of depression. This suggests the identification of additional contributors is necessary to improve our understanding of suicide risk in rural regions. Investigating the independent contribution of depression, and the impact of co-existing psychiatric disorders, to suicidal ideation and suicide attempts in a rural community sample may provide clarification of the role of depression in rural suicidality.


618 participants in the Australian Rural Mental Health Study completed the Composite International Diagnostic Interview, providing assessment of lifetime suicidal ideation and attempts, affective disorders, anxiety disorders and substance-use disorders. Logistic regression analyses explored the independent contribution of depression and additional diagnoses to suicidality. A receiver operating characteristic (ROC) analysis was performed to illustrate the benefit of assessing secondary psychiatric diagnoses when determining suicide risk.


Diagnostic criteria for lifetime depressive disorder were met by 28% (174) of the sample; 25% (154) had a history of suicidal ideation. Overall, 41% (63) of participants with lifetime suicidal ideation and 34% (16) of participants with a lifetime suicide attempt had no history of depression. When lifetime depression was controlled for, suicidal ideation was predicted by younger age, being currently unmarried, and lifetime anxiety or post-traumatic stress disorder. In addition to depression, suicide attempts were predicted by lifetime anxiety and drug use disorders, as well as younger age; being currently married and employed were significant protective factors. The presence of comorbid depression and PTSD significantly increased the odds of reporting a suicide attempt above either of these conditions independently.


While depression contributes significantly to suicidal ideation, and is a key risk factor for suicide attempts, other clinical and demographic factors played an important role in this rural sample. Consideration of the contribution of factors such as substance use and anxiety disorders to suicidal ideation and behaviours may improve our ability to identify individuals at risk of suicide. Acknowledging the contribution of these factors to rural suicide may also result in more effective approaches for the identification and treatment of at-risk individuals.