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Why does Scotland have a higher suicide rate than England? An area-level investigation of health and social factors
  1. Pearl L H Mok1,
  2. Alastair H Leyland2,
  3. Navneet Kapur1,
  4. Kirsten Windfuhr1,
  5. Louis Appleby1,
  6. Stephen Platt3,
  7. Roger T Webb1
  1. 1Centre for Suicide Prevention, Centre for Mental Health and Risk, University of Manchester, Manchester, UK
  2. 2MRC/CSO Social and Public Health Sciences Unit, Glasgow, UK
  3. 3Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
  1. Correspondence to Dr Roger T Webb, Centre for Suicide Prevention, Centre for Mental Health and Risk, University of Manchester, Room 2.311, Jean McFarlane Building, Oxford Road, Manchester M13 9PL, UK; roger.webb{at}


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.

  • Suicide
  • mental health
  • alcohol
  • drug misuse
  • public health
  • psychiatry
  • epidemiology

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  • Funding The study was funded by the Chief Scientist Office (CSO) of the Scottish government. The CSO has no role in the study design, collection, analysis and interpretation of data, and in the writing and in the decision to submit the article for publication.

  • Competing interests None.

  • Ethical approval The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness had ethical approval from South Manchester Medical Research Ethics Committee and latterly the North West Research Ethics Committee as well as approval under Section 60 (now Section 251) of the Mental Health and Social Care Act.

  • Provenance and peer review Not commissioned; externally peer reviewed.