Reducing Suicides by Firearms

Abstract
Suicide by firearm is a public health problem. In 2016, firearm suicides accounted for half of all suicide deaths in the United States. Access to a firearm, particularly during a time of increased risk for suicide (e.g., divorce, job loss), has been identified as a key factor increasing one’s risk for completing suicide. States with higher rates of gun ownership have higher suicide rates than states with low gun ownership, whereas non–firearm suicide rates are comparable, indicating that firearm access drives overall suicide rates. The most promising evidence-based strategies to reduce access to firearms during a period of high risk are (1) temporary relocation of household firearms away from home when a family member is at risk for suicide, (2) safe storage at home if relocation is not possible, (3) working with leaders in the gun community to develop and implement messaging about the preceding two strategies that will be acceptable to gun owners, and (4) increasing screening for and counseling about access to guns by health professionals and other gatekeepers. Working with gun owners, industry, law enforcement, physical and mental health professionals, and researchers is important in decreasing firearm suicides via evidence-based strategies. Declines in firearm suicides do not require decreased gun ownership rates. A concerted social marketing approach can incorporate firearm suicide prevention into standard firearm safety messaging. Moreover, the entertainment industry can model firearm suicide prevention behaviors. Through these efforts, firearm safety can include suicide prevention in a manner fully consistent with the Second Amendment.

Relationship to Existing APHA Policy Statements
The following APHA policy statements are relevant to the current statement:

• APHA Policy Statement 7524(PP): Suicide Prevention
• APHA Policy Statement 9818: Handgun Injury Reduction

This statement supplements 7524 regarding the role of firearms in suicide. Statement 9818 is replaced by this statement.

Problem Statement
According to the Centers for Disease Control and Prevention (CDC), suicide rates in the United States have increased by nearly one third over the past 20 years, with half of U.S. states experiencing an increase above 30% during this period.[1] Rates have risen among both sexes, all racial/ethnic groups, and all age groups under 75 years, as well as in rural, suburban, and urban settings.[2,3] There were 44,965 suicide deaths in the United States in 2016, with an age-adjusted rate of 15.6 per 100,000.[4] Suicide was the second-leading cause of death among individuals 10–14, 15–24, and 25–34 years of age.[5] It was the 10th-leading cause of death among all age groups combined and is one of only three leading causes that are increasing in prevalence.[5,6]

While suicide affects all individuals, males are four times more likely than females to die by suicide,[4] and the prevalence of suicidal thoughts, planning, and attempts is significantly higher among younger age groups (18–29 years) than older age groups.[7] Racial/ethnic and other groups with high suicide rates include American Indians and Alaska Natives, rural populations, and active or retired military personnel.[8] Suicide also affects the health of others; when people die by suicide, their family, friends, and community often experience shock, anger, guilt, and depression.

Suicide is a public health problem both economically and physically. According to the Suicide Prevention Resource Center, the estimated average cost of a single suicide is $1,329,553.[9] Nearly all of this cost (97%) is attributed to lost productivity, with the remaining 3% due to medical treatment. It has been reported that the total cost of suicides and suicide attempts is $70 billion per year.[10]

Multiple risk factors for suicide exist, including a previous suicide attempt (the strongest predictor), a history of depression or other mental illness, alcohol or drug abuse, a family history of suicide or violence, physical illness, and a feeling of being alone.[11,12] However, as evidenced by the far greater prevalence of these factors than of suicide deaths, most people with one or more such risk factors do not go on to die by suicide.[13] While individuals with these risk factors are encouraged to obtain mental health treatment, many of those who die by suicide have no known record of such treatment,[1] indicating a need for additional strategies to increase the safety of people at risk. Reducing access to lethal means is one such strategy.

There is ample evidence that suicidality is transitory. Should a person survive a suicidal impulse, his or her prognosis is quite good. The results of a meta-analysis of nearly 100 studies of suicide attempters showed that 90% of attempters who survive do not go on to die by suicide.[14] In fact, many suicide attempts occur with little planning,[15,16] often in response to a short-term crisis.[17,18] However, if a person attempts suicide through a means that is highly lethal, such as a firearm, the odds of survival are quite low.[19]

One must not opt to make a suicide attempt using a highly lethal means such as a firearm if there is to be any opportunity to obtain mental health treatment or endure a painful short-term crisis. In 2016, 51% of all suicide deaths in the United States (a total of 22,936 deaths) involved firearms, with an age-adjusted rate of 7.8 per 100,000.[4] In nearly every age group, firearms were the leading mechanism for suicide deaths (among 10- to 14-year-olds, they were the second-leading mechanism).[4] Access to firearms is a key risk factor for suicide.[20–23] Several studies have shown that rates of suicide are higher in states with higher levels of gun ownership (but not higher rates of suicide attempts) and that these heightened rates are driven by increases in firearm suicides.[21,22,24] Suicides by methods other than firearms are not significantly different in states with lower or higher overall suicide rates.[24] Multiple reviews offer strong evidence that rises in gun ownership prevalence are associated with increases in firearm suicides, which in turn lead to increases in the overall suicide rate.[25–27] Studies of gun prevalence and suicide rates typically control for multiple potential confounders such as psychological distress, substance use, poverty, education, and unemployment.[22,28,29] They also typically reveal that the relationship between household gun ownership and suicide rates holds for men, women, children 5 to 14 years old, and those in nearly every other age group.[30–32] Decreasing the number of firearm suicides would yield a significant reduction in the overall suicide rate in the United States.[20–22]

A note on terminology: It is recognized in this policy statement that the terms “firearm” and “gun” are not identical in the weapons they cover. Precisely speaking, this statement addresses suicide by firearm. However, in much of the scientific literature, mass media, and common speech, the term gun is used when firearm would be more accurate. Here the term firearm is primarily used; however, in some cases the term gun is used when quoting the literature or referring to programs that use similar language (e.g., gun violence restraining order).

Evidence-Based Strategies to Address the Problem
A number of international studies have indicated that when lethal means are made less available or less deadly, suicide rates by the method in question decline, and often (when the method is commonly used) suicide rates overall decline.[27,33] This has been demonstrated in multiple countries and with a variety of suicide methods: bridges, domestic gas, pesticides, medications, and firearms.[34–38] Decreasing access to firearms is likely to reduce suicide in the United States overall because firearms are the most commonly used method,[4] consistent with their ubiquity in certain regions of the country (personal gun ownership is estimated to be as high as 25% in the South)[39] and high case fatality rate (92% versus 78% for hanging and lower percentages for other methods).[19] In addition, the speed with which one can carry out suicide by firearm increases the odds of a fatal outcome during an unplanned attempt or one involving minimal planning: 25% of attempters make an attempt within 5 minutes of deciding to end their lives.[16] Creating safer environments for those at risk of suicide by reducing their access to highly lethal means is emphasized in the CDC’s technical guidelines for preventing suicide.[8] Numerous U.S.-based studies indicate that the most promising evidence-based strategies to decrease firearm suicides involve reducing access to guns in the following ways: (1) relocation of household firearms away from the home when a family member is at risk for suicide, (2) safe storage at home if relocation is not possible, (3) working with leaders in the gun community to develop and implement messaging about the preceding two strategies that will be favorable to most gun owners, and (4) increasing screening for access to firearms by health professionals and other gatekeepers.

Relocation of household firearms away from home when a family member is at risk for suicide: Between 2003 and 2005, about 90% of all suicides in the Israeli Defense Force (IDF), a mandatory population-based army drafting all youths 18–21 years of age, were firearm suicides. Since many IDF soldiers go home on the weekends, the IDF changed its weapons policy in 2006 to require that firearms remain on base when soldiers take a weekend leave. After this policy change, the overall IDF suicide rate decreased by 40% in 2007–2008. Most of this decrease was due to a reduction in weekend firearm suicides; there was no significant change in weekday suicide rates.[38] A study of suicides in Switzerland showed that when the army halved the number of soldiers from 2003 to 2004 (leading to a decrease in gun availability nationwide), both firearm suicide and overall suicide (but not non-firearm suicide) rates dropped among military-aged men but not military-aged women or older men.[40]

These IDF and Switzerland data support nationwide research indicating that restricting firearm access is effective in decreasing overall suicide rates. Over a 3-year period (2000–2002), the 15 states with the highest household firearm ownership rate (47%) had almost twice as many suicides (14,809) as the six states with the lowest ownership rate (15%; 8,052 suicides). This difference in overall suicides was largely accounted for by the difference in firearm suicides (9,749 versus 2,606). Non-firearm suicides and the total populations of the two sets of states were comparable.[22] During a more recent 2-year period (2008–2009), these findings persisted.[24] If the relationship is causal, these results suggest that a 1% decrease in household firearm ownership could reduce the firearm suicide rate by 3.5% and the overall suicide rate by 1.5%, with even greater effects for adolescents.[22] By extrapolation, reducing household firearm ownership by 5% could prevent about 3,000 suicides per year in the United States.[4] This is not to say, however, that gun owners must sell their firearms in order to reduce firearm suicides. Suicide prevention professionals are having success working with gun owners to help them identify offsite storage options (e.g., firearm retailers, shooting ranges, pawn shops, law enforcement facilities, storage facilities, and family members and friends authorized to store firearms) that will keep loved ones safe while preserving gun ownership rights.[41,42] These options could be temporary or permanent depending on the gun owner and his or her family’s assessment of the benefits and risks of bringing firearms back into the home.

Safe storage of firearms at home: A gun owner may not find temporary relocation of firearms outside the home to be feasible. Gun owners may wish to talk over tenable storage options with loved ones as well as with mental health clinicians or other health professionals. In the event firearms cannot be relocated, numerous studies indicate a reduced risk of firearm suicide when household guns are stored locked and unloaded, with ammunition locked separately.[23,43,44] Having a locked gun closet, keeping firearms unloaded, and locking ammunition or storing it in a different part of the house each reduces the risk of suicide by 55% to 73%.[23] One study revealed that the risk of suicide was three times greater among individuals in households with loaded firearms than among those in homes with unloaded guns. Households with guns stored in unlocked places were associated with more than twice the risk of suicide than households in which firearms were kept in a locked place, and homes with one or more handguns were associated with a risk of suicide almost twice as high as that in homes containing only long guns.[43] An evaluation of a community-based giveaway of gun storage devices indicated a 13% increase in safe storage of firearms.[45] Also, a review of firearm safe storage interventions showed that providing owners with a safety device such as a lock box significantly improved storage practices.[46] Safe storage of firearms in the home is a critical component of reducing firearm suicide.

Education of gun owners on the relationship between firearms and suicide: Since 2009, gun rights advocates and suicide prevention experts have been working together to develop and test messages for gun owners on the importance of temporarily relocating firearms outside the home when a household member is struggling with a mental health or substance abuse problem or going through a painful crisis such as a divorce or job loss. A study of firearm retailers in New Hampshire showed that 48% of retailers that received intervention materials were still using at least one of the materials several months later. Retailers who believed that there was a relationship between firearm accessibility and risk of suicide were more likely to be using intervention materials.[41] Changing social norms related to firearms and safety is critical in intervention efforts and requires spreading accurate information via trusted messengers. Success in changing norms has been shown elsewhere in the public health literature, illustrating the role of advocacy and grassroots efforts, especially when combined with a multicomponent strategy.

For example, campaigns have been effective in spreading messages about the physical dangers and legal consequences of drunk driving.[47] An especially successful organization is Mothers Against Drunk Driving (MADD). Through its widespread programs, services, and legislative efforts, MADD has influenced social norms related to drinking and driving such that the number of U.S. alcohol-related auto fatalities fell from 25,000 to 17,000 between 1982 and 2003, while the number of auto fatalities from crashes unrelated to alcohol increased from 18,000 to 25,000.[48,49] During that time, the entertainment industry worked with public health experts to promote the “designated driver” campaign on popular television shows.[50] The industry has also worked with public health experts to promote the use of checklists during surgery, educate the public about human papillomavirus (HPV) and HIV, reduce the occurrence of smoking in youth-rated movies, and publicize countless other public health issues.[51–53] The American Foundation for Suicide Prevention’s recent partnership with the National Shooting Sports Foundation is an important step toward communicating effectively with gun owners about preventing firearm suicides.[54]

Increasing screening for access to firearms: Doctors, nurses, mental health providers, and other health professionals have a critical opportunity to increase awareness about the link between firearms and suicide among those living in homes with firearms. Many people considering suicide do not seek mental health services, so it is important for primary care providers, emergency department (ED) doctors, and other health providers to screen for access to firearms, even among patients without mental health concerns.[55,56] One study showed a threefold increase in actions intended to limit access to household firearms among parents who brought their children to an ED for mental health treatment and received counseling on firearm access relative to those who did not receive counseling in the ED.[57] A more recent study revealed an increase in safe storage of firearms after ED-based counseling.[58] In spite of this, another recent study showed that only 18% of suicidal patients presenting at an ED received a lethal means assessment, with only 8% of these individuals receiving actual counseling on how to reduce access to lethal means.[59] Surveys of providers have shown that only 50% usually screen for access to firearms among suicidal patients, even though most think it is important to do so.[60] There are resources available to educate providers on the importance of conducting lethal means counseling and how to do so in a way that is respectful of the right to own guns.[61]

Each of these four strategies would benefit greatly from funding to further examine effective methods of implementation, but suicide prevention research is woefully underfunded. Alcoholism receives five times more research funding for 50% more deaths, and breast cancer receives nearly seven times more funding for fewer annual deaths.[62]

Opposing Arguments/Evidence
Firearm suicide is a public health issue wrought with assumptions and misinformation. While suicide is a subject familiar to Americans, guns as a suicidal determinant are underestimated. A common assumption is that suicide is premeditated, giving a person ample time to obtain access to a highly lethal means such as a firearm. While some suicides are planned, many suicide attempts occur within less than an hour of thinking about them.[15,16] Depression and substance abuse are risk factors for suicide that a person may be managing long term, but the elevated risk of a suicidal attempt is often short and fleeting.[16,63] A person experiencing an acutely distressing incident may respond impulsively to suicidal thoughts.[63] If this person does not have access to a highly lethal means such as a firearm during this crisis, she or he is more likely to survive the crisis either by attempting suicide with a less lethal means and surviving or by opting not to make an attempt at all.[27]

It is often argued that someone suicidal cannot be stopped, regardless of what methods are readily available. This implies that someone who survives a suicide attempt will simply die by suicide in a subsequent attempt. While there are certainly some suicides that cannot be prevented, as previously mentioned, a review of nearly 100 studies determined that 90% of people who attempted suicide and survived did not go on to die by suicide later.[14] One is more likely to survive a suicide attempt if one does not use the most highly lethal means available to make that attempt. Firearm suicide is the suicide method with the highest case fatality rate, with over 90% of attempts resulting in death.[19] By contrast, case fatality rates for hanging, carbon monoxide poisoning, and drug poisoning are 61%, 42%, and 2%, respectively.[19] Most people who die by suicide have not made an earlier attempt.[64,65] Their choice of method does not leave room for a change of heart later, whereas other methods do, and we see the change of heart in the literature on those who survive suicide attempts. Unfortunately, a firearm typically results in death after only one attempt.[66]

Those opposed to reducing firearm access have pointed out that some countries have high suicide rates but low firearm ownership rates. The effectiveness of means restriction in suicide reduction is well documented across a variety of means. Australian suicide rates decreased as barbiturate access was restricted.[67] Suicide in Asia dropped once access to pesticide, the most common means of suicide in the region, was limited.[36] In the United Kingdom in the 1960s, carbon monoxide levels in domestic gas were reduced from 20% to nearly 0%, corresponding with a 30% decrease in the suicide rate.[35] Countries seeking to reduce their suicide rate should contemplate means reduction strategies for the methods most likely to effect a sizeable reduction in suicides among their population. In the United States, firearms are the most common method of suicide.[20,27,63]

When asked about offering gun storage, some retailers have expressed concern about liability risks should a death occur once the firearm has been returned to the owner.[68] Having discussed this issue with lawyers familiar with relevant case law, the authors are unaware of any evidence of legal liability for events that might occur when a gun is returned.[69]

Some would oppose reducing access to lethal means because this would make a firearm unavailable for self-defense. Each household must weigh the likelihood of needing a firearm for self-defense against the likelihood of that firearm being used in a suicide or other gun death. These odds may well change repeatedly over time and can be reassessed regularly.

There have also been challenges to the professional autonomy of doctors involving the powers of the state to limit the topics that physicians can discuss with patients. In Florida, an act that prohibited physicians from asking patients about firearm ownership and storage was ruled invalid by the courts.[70] While there is the possibility of additional attempts to gag medical professionals, this ruling supports the rights of physicians.

Alternative Strategies
In popular media regarding firearm violence, both self-directed and outward, mental health care is often raised as the most important method for preventing shooting deaths.[71] The importance of access to mental health treatment cannot be denied. However, a recent CDC report noted that 54% of suicide decedents in 27 states in 2015 did not have a known mental health condition.[1] If, for the sake of argument, it is assumed that those decedents had an undiagnosed mental illness, it must be acknowledged that a lethal suicide attempt cut short the available time for persuading them to seek help. The pervasive stigma against acknowledging mental health struggles, as well as the lack of a cure for mental illnesses, must also be noted. The mental health field cannot be solely responsible for the universe of people at risk for suicide. Support from public health can be offered around how to talk about firearms with patients and their loved ones, as well as around information about local storage options for families seeking alternatives to storing firearms at home. Furthermore, the majority of people living with mental illness will not attempt suicide, and predicting who among them will is a very inexact science.[71] It is important not to reduce their propensity to seek treatment by categorically infringing upon their rights (e.g., by prohibiting anyone who has ever been diagnosed with a mental illness from owning a firearm).[72,73] Moreover, research into the impact of mental health on suicide has demonstrated that firearm access has independent effects on risk above and beyond other covarying risk factors, including mental illness. [24]

There are two other ways to reduce access to guns among those at risk for suicide that are more controversial and lack sufficient evidence to currently promote their implementation as firearm suicide prevention strategies: gun violence restraining orders (or other legislative approaches) and smart gun technology.

Gun violence restraining orders allow family members, intimate partners, and law enforcement personnel to formally request confiscation of firearms that belong to someone at risk of hurting him- or herself or others. These orders are fairly new, and their efficacy is as yet undetermined regarding firearm suicide prevention.[74] It is worth noting that 30% to 40% of firearm sales take place in the secondary market, where sellers are unlicensed, meaning that law enforcement cannot rely on a database to know what guns are in the home to confiscate.[75] Furthermore, a detailed discussion of legislative approaches in general was left out of this policy statement for several reasons. First, studies of firearm legislation and suicide, even those controlling for gun ownership rates, have been unable to demonstrate an actual reduction in firearm availability stemming from such legislation.[27] Second, the U.S. gun stock is so large relative to the marginal firearm likely to be affected by a given piece of legislation that, similar to Azrael and Miller,[27] the authors of this statement are unwilling to assume that firearm exposures have changed sufficiently to impact suicide rates as a result of said legislation. Finally, legislating gun access stands to further deepen the divide between gun owners and non–gun owners. Instead, health professionals can support innovative work being done within suicide prevention to regard gun owners as part of the solution rather than part of the problem.[76–78] With more research, strategies to reduce firearm suicide deaths may involve contemplating a legislative agenda; however, gun owners may not be receptive. This would be counterproductive to efforts regarding the present policy.

Smart gun technology prevents unauthorized use of a firearm by rendering it inoperable for anyone other than the owner. This could potentially prevent many suicidal individuals from obtaining quick access to a firearm, especially in the home (e.g., adolescents). However, this technology is not sufficiently widespread to evaluate its impact on firearm suicide,[26] and support for such an approach among gun owners is limited.[79]

Action Steps

1. Mental health advocates and governing associations for mental health professionals should adopt and promote available guidelines for mental health providers on screening for guns in the home if a client/patient is having a psychiatric crisis or has a chronic mental illness.[58,61] State-level professional associations should equip mental health providers with information about local offsite storage options when available for families that need to temporarily or permanently relocate their firearms outside the home.
2. State associations affiliated with national organizations such as the American Academy of Pediatrics and the American Medical Association, or accreditors such as the Joint Commission and the American College of Surgeons, should adopt and promote guidelines promulgated by their parent organizations advocating screening for firearms in the home along with counseling so that lethal means reduction awareness can be spread in general office appointments and emergency departments and safe storage strategies can be discussed, in addition to provision of firearm safety devices when possible.
3. State public health agencies should collaborate with public safety and mental health agencies to advocate for an increase in the availability of temporary firearm storage outside the home. Law enforcement personnel, firearm retailers, range owners, instructors, and other leaders in the firearms community are important partners, as they can provide low-cost gun storage for clients and normalize the inclusion of suicide prevention in gun safety education.
4. Public safety agencies should work with the legal community to educate law enforcement personnel and retailers/range owners about their rights and protections should they offer firearm storage.
5. Public health and mental health agencies should collaborate with firearm owners to increase awareness of the importance of lethal means reduction when a loved one is at risk for suicide. It is important to include gun owners as part of the solution instead of assuming that they are opposed to safety measures when it comes to firearm suicides.
6. Public health agencies and advocates should collaborate with the entertainment industry as well as the news media and communications firms to support safe storage practices. Films, television shows, news stories, and so forth should provide venues to normalize messaging on gun access in instances in which there is concern about someone’s risk for suicide (whether on the part of a parent, spouse, health provider, teacher, or other concerned stakeholder).
7. Public health agencies should collaborate with gun owners and suicide prevention professionals to advocate for increased public and private funding of firearm suicide research. A small number of private foundations and funders have shouldered an undue portion of the responsibility to fund firearm research efforts, as support from the federal government and large foundations is minimal. Public agencies should work with foundations and private funders to develop funding opportunities that support firearm suicide prevention.[78] Such efforts should include development and evaluation of firearm safety education that incorporates suicide prevention and development of social marketing campaigns around firearm suicide prevention.

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