More than half of the youths who killed themselves in this time period did so with a firearm, and gun suicides (though generally on the decline) were particularly common in rural areas—nearly three times more common. This may be because gun ownership is higher in rural regions. According to 2014 Pew data, 51 percent of people in rural areas kept a gun at home, compared to 25 percent in urban areas, and 36 percent in the suburbs.

“Suicide is in many ways the oft-ignored part of gun tragedy in America, the part that few talk about, especially those who resist any efforts to decrease access to guns,” writes Frederick Rivara, a professor of pediatrics at the University of Washington, in an editorial accompanying the study. He points out that 86 percent of suicide attempts using guns end in death, compared to 2 percent of attempts using drugs.

“Rural residents often grow up with guns, have guns in their homes and there’s just a general culture of guns in rural areas,” Fontanella says. Even so, she says, suicide rates by all methods were higher in the country than in the city.