OBJECTIVE: To evaluate differences in mental health and substance use circumstances by rurality and military affiliations among suicide decedents. METHODS: Multiyear (2009-2019) cross-sectional study of adult suicide decedents reported to the National Violent Death Reporting System. We classified suicide decedents into a four-level variable by geography (urban/rural) and military status and evaluated the prevalence of current and past alcohol and substance use problems, mental health problem recognition and mental illness treatment. We estimated prevalence ratios using multiple imputation chain equations to account for missing data and log-binomial regression models and present stratified estimates by military and rural classification. FINDINGS: There was no significant relationship between rural-military classification and alcohol use problem. Compared with urban civilians, other groups had a lower risk identified of having a substance use problem: urban military (adjusted prevalence ratio (aPR): 0.65
95% CI: 0.60 to 0.71), rural military (aPR: 0.57
95% CI: 0.50 to 0.66) and rural civilians (aPR: 0.95
95% CI: 0.90 to 1.00). Recognition of a mental health problem was lower among both rural military (aPR: 0.88
95% CI: 0.81 to 0.96) and rural civilians (aPR: 0.89
95% CI: 0.86 to 0.92). The likelihood of current mental treatment was lower in other groups (urban military (aPR: 0.93
95% CI: 0.89 to 0.96)
rural military (aPR: 0.87
95% CI: 0.81 to 0.94)
and rural civilian (aPR: 0.89
95% CI: 0.85 to 0.92)). There was no evidence of effect modification by military and rural classification for any outcome. CONCLUSIONS: Mental health outcomes by military affiliation and urbanicity/rurality may need to be independently assessed as social determinants of health.