Brenner, Barry, David Cheng, Sunday Clark, and Carlos A. Camargo, Jr. Positive association between altitude and suicide in 2584 U.S.counties. High Alt. Med. Biol. 12: 31-35 2011.-Suicide is an important public health problem worldwide. Recent preliminary studies have reported a positive correlation between mean altitude and the suicide rate of the 48 contiguous U.S.states. Because intrastate altitude may have large variation, we examined all 2584 U.S. counties to evaluate whether an independent relationship between altitude and suicide exists. We hypothesized that counties at higher elevation would have higher suicide rates. This retrospective study examines 20 yr of county-specific mortality data from 1979 to 1998. County altitude was obtained from the U.S. Geologic Survey. Statistical analysis included Pearson correlation, t tests, and multivariable linear and logistic regression. Although there was a negative correlation between county altitude and all-cause mortality (r = -0.31, p < 0.001), there was a strong positive correlation between altitude and suicide rate (r = 0.50, p < 0.001). Mean altitude differed in the 50 counties, with the highest suicide rates compared to those with the lowest rates (4684 vs. 582 ft, p < 0.001). Controlling for percent of age >50 yr, percent male, percent white, median household income, and population density of each county, the higher-altitude counties had significantly higher suicide rates than the lower-altitude counties. Similar findings were observed for both firearm-related suicides (59% of suicides) and nonfirearm-related suicides. We conclude that altitude may be a novel risk factor for suicide in the contiguous United States.