[ Spring 2013 ]
Special Report
by Madeline Drexler, Editor, Harvard Public Health
There’s a gas station maybe a five-minute drive away from us, and the gas station sells guns. I didn’t realize places like that existed. Ryan just walked in and bought a handgun. We had gotten into an argument—which we hardly ever did—and he left. The next morning, the police knocked on my door. A construction crew had found him dead in his car at an abandoned railroad station.
— Emily Frazier, 27, widow of Ryan Frazier, who shot himself with a semiautomatic in 2008.
In the national debate over gun violence—a debate stoked by mass murders such as last December’s tragedy in a Newtown, Connecticut, elementary school—a glaring fact gets obscured: Far more people kill themselves with a firearm each year than are murdered with one. In 2010 in the U.S., 19,392 people committed suicide with guns, compared with 11,078 who were killed by others. According to Matthew Miller, associate director of the Harvard Injury Control Research Center (HICRC) at Harvard School of Public Health, “If every life is important, and if you’re trying to save people from dying by gunfire, then you can’t ignore nearly two-thirds of the people who are dying.”
Suicide is the 10th-leading cause of death in the U.S.; in 2010, 38,364 people killed themselves. In more than half of these cases, they used firearms. Indeed, more people in this country kill themselves with guns than with all other intentional means combined, including hanging, poisoning or overdose, jumping, or cutting.
Though guns are not the most common method by which people attempt suicide, they are the most lethal. About 85 percent of suicide attempts with a firearm end in death. (Drug overdose, the most widely used method in suicide attempts, is fatal in less than 3 percent of cases.) Moreover, guns are an irreversible solution to what is often a passing crisis. Suicidal individuals who take pills or inhale car exhaust or use razors have time to reconsider their actions or summon help. With a firearm, once the trigger is pulled, there’s no turning back.
Not “Why?” but “How?”
When we think of suicide, we usually think of a desperate act capping years of torment. According to the National Institute of Mental Health, complex and deep-rooted problems—such as depression and other mental disorders, drug and alcohol abuse, family violence, and a family history of suicide—often shadow victims. Suicide among males is four times higher than among females. In adults, separation or divorce raises the risk of suicide attempts. In young people, physical or sexual abuse and disruptive behavior increase vulnerability.
The harrowing fact of suicide demands a story: “Why?” But from a public health perspective, an equally illuminating question is “How?”
Intent matters, but so does method, because the method by which one attempts suicide has a great deal to do with whether one lives or dies. What makes guns the most common mode of suicide in this country? The answer: They are both lethal and accessible. About one in three American households contains a gun.
The price of this easy access is high. Gun owners and their families are much more likely to kill themselves than are non-gun-owners. A 2008 study by Miller and David Hemenway, HICRC director and author of the book Private Guns, Public Health, found that rates of firearm suicides in states with the highest rates of gun ownership are 3.7 times higher for men and 7.9 times higher for women, compared with states with the lowest gun ownership—though the rates of non-firearm suicides are about the same. A gun in the home raises the suicide risk for everyone: gun owner, spouse and children alike.
This stark connection holds true even when other factors are taken into account. “It was a reasonable hypothesis to think that the type of person who chooses to own a gun is different from the type of person who chooses not to. Maybe there’s a ‘go-it-alone’ attitude that leads to less help seeking. Or maybe gun owners are more likely to live in rural areas, and rural locales are associated with greater suicidality,” explains Catherine Barber, director of HICRC’s Means Matter campaign, a suicide prevention effort that focuses on the ways people attempt to take their own lives.
“But when we compared people in gun-owning households to people not in gun-owning households, there was no difference in terms of rates of mental illness or in terms of the proportion saying that they had seriously considered suicide,” Barber says. “Actually, among gun owners, a smaller proportion say that they had attempted suicide. So it’s not that gun owners are more suicidal. It’s that they’re more likely to die in the event that they become suicidal, because they are using a gun.”
While gun-suicide rates are higher in rural states, which have proportionally more gun owners, the gun-suicide link plays out in urban areas, too. “In the early 1990s, the dramatic rise in young black male suicides was in lock step with the homicide epidemic of those years,” says HSPH’s Deborah Azrael, associate director of the Harvard Youth Violence Prevention Center. “Young black male suicide rates approached those of young white males—though black suicide rates had always been much lower than white suicide rates. It was entirely attributable to an increase in suicide by firearms.”
Put simply, the fatal link applies across the board. “It’s true of men, it’s true of women, it’s true of kids. It’s true of blacks, it’s true of whites,” says Azrael. “Cut it however you want: In places where exposure to guns is higher, more people die of suicide.”
Impulsive acts
The scientific study of suicide has partly been an effort to erase myths. Perhaps the biggest fallacy is that suicides are typically long-planned deeds. While this can be true—people who attempt suicide often face a cascade of problems—empirical evidence suggests that they act in a moment of brief but heightened vulnerability.
“One of the things that got me interested in launching the Means Matter campaign was that I had been reading through thousands of thumbnail sketches of suicide deaths, to see if a reporting system we were testing was catching the feel for the case,” says Barber. “I started noticing that, jeez, this death happened the same day that the kid was arguing with his parents, or that the young man had just broken up with his girlfriend, or that the middle-aged guy had gotten word that the divorce papers had come through. That reactivity surprised me, because I’d always pictured suicide as being a painful, deliberative process, something that was getting worse and worse, escalating until finally you’ve got it all planned out and you do it. It hadn’t occurred to me that it could be a cop arguing with his wife, and in the midst of the argument, pulling out his gun and killing himself.”
This impulsivity was underscored in a 2001 study in Houston of people ages 13 to 34 who had survived a near-lethal suicide attempt. Asked how much time had passed between when they decided to take their lives and when they actually made the attempt, a startling 24 percent said less than 5 minutes; 48 percent said less than 20 minutes; 70 percent said less than one hour; and 86 percent said less than eight hours.
The episodic nature of suicidal feelings is also borne out in the aftermath: 9 out of 10 people who attempt suicide and survive do not go on to die by suicide later. As Miller puts it, “If you save a life in the short run, you likely save a life in the long run.”
Lethal environments
A central tenet of public health is that environment shapes individual behavior. In the realm of suicide, this truth has played out dramatically in recent history. When widely used lethal means are made less available or less deadly, suicide rates by that method decline, as do suicide rates overall. In Sri Lanka, for example, where pesticides are the leading suicide method, the suicide rate fell by half between 1995 and 2005, after the most highly human-toxic pesticides were restricted.
Similarly, in the United Kingdom before the 1950s, domestic gas derived from coal contained 10 to 20 percent carbon monoxide, and poisoning by gas inhalation was the leading means of suicide. A source of natural gas virtually free of carbon monoxide was introduced in 1958; over time, as carbon monoxide in gas decreased, so did the number of suicides overall—driven by a drop in carbon monoxide suicides, even as other methods increased somewhat.
Changing the means by which people try to kill themselves doesn’t necessarily ease the suicidal impulse or even the rate of attempts. But it does save lives by reducing the deadliness of those attempts.
Dearth of data
Though these basic facts are known, there is a striking dearth of research on guns and suicide. In the U.S., government officials don’t even have current data on where household gun ownership rates are higher or lower. The only survey large enough to produce state-level estimates of gun ownership was conducted by the federal Behavioral Risk Factor Surveillance System, the world’s largest ongoing telephone health survey. The survey asked questions about gun ownership in 2001, 2002 and, for the last time, in 2004. It was HICRC investigators who analyzed this state-level data to show that suicide rates run in tandem with gun ownership rates.
Today, the U.S. Centers for Disease Control and Prevention’s National Violent Death Reporting System, which collects data from police and coroners’ reports and death certificates on every suicide and homicide, covers only 18 states. Compare this with the National Highway Traffic Safety Administration’s Fatality Analysis Reporting System, which amasses extensive details within 30 days of every fatal car crash on public roads, from the time and location of the accident to weather conditions to the role of alcohol and drugs. Partly as a result of this bureaucratic diligence, the fatality rate from car crashes has dropped by about a third over the last two decades. Could the same dedication bring down suicides?
Matthew Miller thinks it can. “Better data is a good place to start. That way, discussions are grounded in facts rather than distorted by ideology. It can only help foster social-norm-shifting conversations similar to those that took place around cigarette smoking, safety belt use and driving drunk,” he says. “I’d like physicians to feel it’s their responsibility to tell people about the risks. There’s no reason that you should have a conversation about a bike helmet or a seat belt, but not firearms.”
But change also takes time. “With public health, when you don’t have the one-size-fits-all solution, you chip away at the problem,” says Barber. Preventing suicides will likely require many approaches, from education and media campaigns to skilled treatment and community support. Ultimately, the goal is to transcend politics—which is why those who have lost loved ones to gun suicide should have the last word:
Ryan is my baby. I remember once telling him, “If anything happens to you, I would cease to exist.” And that’s what it feels like. It’s a pain like no other. I would encourage open conversation—actually talking about it. Preventing just one person from going through what I went through and will go through for the rest of my life—that would be enough for me.
— Wendy Tapp, mother of 19-year-old Ryan Tapp, who shot himself with a handgun in 2011
Part 2: Starting a Conversation
Survivor Profiles
“He was struggling with nightmares.”
“I couldn’t tell people that my father had died of suicide.”
“A club I never wanted to join.”
Download a PDF of Guns & Suicide: The Hidden Toll