Suicide rates are often high in rural areas.  Despite the strong association between deliberate self-harm (DSH) and suicide, few have studied rural residence and DSH.  Self-poisonings dominate DSH hospital presentations.  The authors investigate a previously reported association between rural residence and medical severity (defined as a subsequent medical/surgical inpatient stay) among emergency department presentations for medicinal self-poisoning (SP) to determine whether differences in agents taken, mental health service use or hospital-level resources explain the relationship.

A cohort of n=16,294 12–64-year olds presenting with SP to hospital emergency departments in Ontario, Canada, in 2001/2002 was linked to their service records over time.

The rural–medical severity association was best explained by differences in hospital resources; presenting to hospitals providing inpatient psychiatric services appeared to reduce medical/surgical inpatient stays in favor of psychiatric ones.  Among those with a recent psychiatric admission, more intensive ambulatory psychiatric contact may be protective of a psychiatric inpatient stay subsequent to the SP presentation.  Compared to nonrural residents, deliberate intent was identified less often in rural residents, particularly males.

The rural–medical severity association was best explained by disparities in the delivery systems serving rural and nonrural residents, important to rural suicide prevention efforts.