We studied rural-urban differences in the prevalence of Diagnostic Interview Schedule (DIS)-DSM-III alcohol abuse or dependence from a community survey (part of the Epidemiologic Catchment Area program) of 3921 adults living in the Piedmont of North Carolina. Bivariate analyses disclosed that current alcohol-related problems, as identified by the DIS, were more common in the rural area (4.2% vs 2.6%). In a logistic regression analysis that controlled for potential confounders, including age, sex, race, socioeconomic status, and the DIS-DSM-III diagnoses of major depression and antisocial personality disorder, the elevated odds of alcohol abuse or dependence in the rural area remained significant for the interactive variable "rural blacks" (relative risk, 2.88). Factors leading to urban-rural differences in psychiatric disorders, such as current alcohol abuse or dependence, are therefore more complex than can be explained by geographic boundaries alone.