Background Up until the mid–late 2000s, the national suicide rate in Scotland was the highest among all the UK countries, but the reasons for this phenomenon are poorly understood.

Methods In a multilevel study of suicide risk in Scotland and England during 2001–2006, the authors examined a range of social, cultural and health-related factors at small area level: postcode sector and Health Board in Scotland and ward and Primary Care Organisation in England.

Results Scotland's national suicide rate was 79% higher than in England (rate ratio 1.79, 95% CI 1.62 to 1.98), with younger male and female Scots aged 15–44 years having double the risk compared with their English peers. Overall, 57% of the excess suicide risk in Scotland was explained by a range of area-level measures, including prescriptions for psychotropic drugs, alcohol and drug use, socioeconomic deprivation, social fragmentation, and other health-related indices. The use of psychotropic drugs, acting as a proxy measure for mental ill health, was the variable most strongly associated with the between-country differences in suicide risk. Alcohol misuse also made an important contribution to the differentials. Overall, the contribution of socioeconomic deprivation and social fragmentation was relatively small.

Conclusions Any attempt to reverse the divergent trend in suicide between Scotland and England will require initiatives to prevent and treat mental ill health and to tackle alcohol and drug misuse. Differences in prescribing rates, however, may also be explained by differences in illness behaviour or the availability of psychosocial interventions, and addressing these may also reduce Scotland's excess risk.