Suicide

We performed reviews of the academic literature on the effects of gun availability on suicide rates.  The preponderance of current evidence indicates that gun availability is a risk factor for youth suicide in the United States.  The evidence that gun availability increases the suicide rates of adults is credible, but is currently less compelling.  Most of the disaggregate findings of particular studies (e.g. handguns are more of a risk factor than long guns, guns stored unlocked pose a greater risk than guns stored locked) are suggestive but not yet well established.

Miller, Matthew; Hemenway, David.  The relationship between firearms and suicide: A review of the literature.  Aggression and Violent Behavior: A Review Journal.  1999; 4:59-75.

Miller, Matthew; Hemenway, David.  Gun prevalence and the risk of suicide: A review.  Harvard Health Policy Review.  2001; 2:29-37.

Using a validated proxy for firearm ownership rates, we analyzed the relationship between firearm availability and suicide across 50 states over a ten-year period (1988-1997).  After controlling for poverty and urbanization, for every age group, across the United States, people in states with many guns have elevated rates of suicide, particularly firearm suicide.

Miller, Matthew; Azrael, Deborah; Hemenway, David.  Household firearm ownership levels and suicide across U.S. regions and states, 1988-1997.  Epidemiology.  2002; 13:517-524.

Using survey data on rates of household gun ownership, we examined the association between gun availability and suicide across states, 1999-2001.  States with higher levels of household gun ownership had higher rates of firearm suicide and overall suicide.  This relationship held for both genders and all age groups.  It remained true after accounting for poverty, urbanization and unemployment.  There was no association between gun prevalence and non-firearm suicide.

Miller, Matthew; Lippmann, Steven; Azrael, Deborah; Hemenway, David.  Household firearm ownership and rates of suicide across U.S. states.  Journal of Trauma.  2007; 62:1029-35.

Using survey data on rates of household gun ownership, we examined the association between gun availability and suicide over time, 1981-2001.  Changes in the levels of household firearm gun ownership was significantly associated with changes in both firearm suicide and overall suicide, for men, women and children, even after controlling for region, unemployment, alcohol consumption and poverty.  There was no relationship between changes in gun ownership and changes in non-firearm suicide.

Miller, Matthew; Azrael, Deborah; Hepburn, Lisa; Hemenway, David; Lippman, Steven.  “The association between changes in household firearm ownership and rates of suicide in the United States, 1981-2002.”  Injury Prevention.  2006; 12:178-82.

We analyzed data on suicide and suicide attempts for states in the Northeast.  Even after controlling for rates of attempted suicide, states with more guns had higher rates of suicide.

Miller, Matthew; Hemenway, David; Azrael, Deborah.  Firearms and suicide in the Northeast.  Journal of Trauma.  2004; 57:626-632.

We analyzed the relationship of gun availability and suicide among differing age groups across the 9 US regions. After controlling for divorce, education, unemployment, poverty and urbanization, the statistically significant relationship holds for 15 to 24 year-olds and 45 to 84 year-olds, but not for 25 to 44 year-olds.

Birckmayer, Johanna; Hemenway, David.  Suicide and gun prevalence: Are youth disproportionately affected?  Suicide and Life Threatening Behavior.  2001; 31:303-310.

We analyzed the relationship of gun availability and suicide among differing age groups across the 9 US regions.  Levels of gun ownership are highly correlated with suicide rates across all age groups, even after controlling for lifetime major depression and serious suicidal thoughts.

Hemenway, David; Miller, Matthew.  The association of rates of household handgun ownership, lifetime major depression and serious suicidal thoughts with rates of suicide across US census regions.  Injury Prevention.  2002; 8:313-16.

We added questions to, and analyzed data from the National Comorbidity Study.

Gun owning households do not have more mental health problems than non-gun owning households; differences in mental health do not explain why gun owners and their families are at higher risk for completed suicide than non-gun owning families.

Miller, Matthew; Molnar, Beth; Barber, Catherine; Hemenway, David; Azrael, Deborah.  Recent psychopathology, suicidal thoughts and suicide attempts in households with vs. without firearms: findings from the National Comorbidity Study Replication.  Injury Prevention.  2009; 15:183-87.

We analyzed data from the Second Injury Control and Risk Survey, a 2001-2003 representative telephone survey of U.S. households. Of over 9,000 respondents, 7% reported past-year suicidal thoughts, and 21% of these had a plan.  Respondents with firearms in the home were no more likely to report suicidal thoughts, plans or attempts, but if they had a suicidal plan, it was much more likely to involve firearms.  The higher rates of suicide among gun owners and their families cannot be explained by higher rates of suicidal behavior, but can be explained by easy access to a gun.

Betz, Marian E; Barber, Catherine; Miller, Matthew.  Suicidal behavior and firearm access: results from the second injury control and risk survey (ICARIS-2).  Suicide and Life Threatening Behaviors.  2011; 41:384-91.

The vast majority of adolescent suicide guns come from parents or other family members.

Johnson, Rene M; Barber, Catherine; Azrael, Deborah; Clark, David E; Hemenway, David.  Who are the owners of firearms used in adolescent suicides?  Suicide and Life Threatening Behavior.  2010; 40:609-611.

Across the Northeast, case fatality rates ranged from over 90% for firearms to under 5% for drug overdoses, cutting and piercing (the most common methods of attempted suicide).  Hospital workers rarely see the type of suicide (firearm suicide) that is most likely to end in death.

Miller, Matthew; Azrael, Deborah; Hemenway, David.  The epidemiology of case fatality rates for suicide in the Northeast.  Annals of Emergency Medicine.  2004; 723-30.

Over 2,700 respondents to a national random-digit-dial telephone survey were asked to estimate how many of the more than 1,000 people who had jumped from the Golden Gate Bridge would have gone on to commit suicide some other way if an effective suicide barrier had been installed.  Over 1/3 of respondents estimated that none of the suicides could have been prevented.  Respondents most likely to believe that no one could have been saved were cigarette smokers and gun owners.

Miller, Matthew; Azrael, Deborah; Hemenway, David.  Belief in the inevitability of suicide: Results from a national survey.  Suicide and Life Threatening Behavior.  2006; 36:1-11.

This article summarizes recent additions to the scientific literature about means restriction policies and suicide.

Johnson, Rene M; Coyne-Beasley, Tamera. Lethal means reduction: What have we learned? Current Opinion in Pediatrics. 2009; 21: 635–640

This introduction to suicide as an international public health problem examines the role of promoting mental health, changing cultural norms, and reducing the availability of lethal means in preventing suicide.

Barber, Catherine; Miller, Matthew. A public health approach to preventing suicide. In: Finkel, Madelon L. Perspectives in Public Health: Challenges for the Future. Santa Barbara CA: Praeger Publishers, 2010.

This summary of the scientific literature on suicide in the United States emphasizes the importance of levels of household firearm ownership in explaining different rates of suicide over time and across states, households and genders.

Miller, Matthew; Azrael, Deborah; Barber, Catherine. Suicide mortality in the United States: The importance of attending to method in understanding population-level disparities in the burden of suicide. Annual Review of Public Health. 2012; 33:393-408.

Using data from recently available state-level suicide attempt data, this study examines whether the association between state-level firearm ownership and completed suicide remains after accounting for suicide attempt rates. Results show that firearm ownership rates – independent of underlying rates of suicidal behavior – largely explain the variation in suicide mortality across the 50 states.

This study answers skeptics of the empirical literature who claim that the association between firearm ownership and suicide mortality reflects unmeasured suicidal proclivities associated with firearm ownership.

Miller, Matthew; Barber, Catherine; Azrael, Deborah; White R. Firearms and suicide in the United States: Is risk independent of underlying suicidal behavior? American Journal of Epidemiology. 2013; 178: 946-55.

Across metropolitan statistical areas that are comprised of large U.S. cities, higher rates of firearm ownership are strongly associated with higher rates of firearm suicide and overall suicide, but not with non-firearm suicide. This study provides evidence consistent with previous case-control work and ecological studies across states and regions that firearms in the home increase the suicide risk.

We had previously shown that levels of household gun ownership largely explain the differences in suicide rates across regions and states. This article shows that gun ownership levels also explain much of the differences in suicide rates across

cities. It is not altitude or remoteness from medical care facilities that can explain this gun-suicide connection.

Miller M, Warren M, Azrael D, Hemenway D. Firearms and suicide in US cities. Injury and Prevention. 2015: 21:e116-e119.

This article describes the New Hampshire gun shop project. After a spate of firearm suicides, a committee of firearm dealers, firearm rights advocates, and suicide prevention professionals including HICRC worked on ways to help gun shops help prevent suicide. Within a couple of years, half of New Hampshire gun shops were using suicide prevention materials developed by the committee.

The gun shop project has become a model of cooperation between public health professionals and gun advocates, a model that is being rolled out throughout the nation. This is the first academic article describing the cooperation and documenting its success. HICRC personnel took the lead on the campaign’s written materials and the pre- and post-campaign interviews with gun shop owners.

Vriniotis M, Barber C, Frank E, Demicco R, and the NH Firearm Safety Coalition. A suicide prevention campaign for firearm dealers in New Hampshire. Suicide and Life-Threatening Behavior. 2015; 45(2): 157-163.

This paper describes (a) the evidence about guns and suicide; (b) the types of voluntary programs (not command-and-control legislation) that will reduce firearm suicides, and (c) the research needed that can help create effective programs.

The National Action Alliance for Suicide Prevention and the National Institute of Mental Health (NIMH) asked HICRC to write priorities for firearm research. This article describes a research agenda that will provide the knowledge to make a means restriction approach successful.

Barber C & Miller M. Reducing a suicidal person’s access to lethal means of suicide: A research agenda. American Journal of Preventive Medicine. 2014; 47(3):S264-72.

This cross-sectional analysis of U.S. counties and states shows that differences in rates of suicide are not explained by differences in antidepressant medication, but are explained by levels of household firearm ownership.

Some mental health professionals have been claiming that antidepressant medication deserves the credit for the fall in suicide in the 1990s, and is the major reason some states have low suicide rates. This article shows that it’s the guns.

This article received the Jess Krauss award as the best article in Injury Epidemiology for the year 2014.

Opoliner A, Azrael D, Barber C, Fitzmaurice G, Miller M. Explaining geographic patterns of suicide in the U.S.: The role of firearms and antidepressants. Injury Epidemiology. 2014; March 20, 1:6.

This essay, in the leading suicide textbook in the field, should help medical professionals to begin to use the Means Matter approach at the individual patient level and to promote it at the societal level.

Azrael D, Miller M. Reducing access to lethal means: A review of the evidence base. In: The International Handbook of Suicide and Attempted Suicide, 2nd ed. West Sussex, England: John Wiley & Sons. 2015.

This article demonstrates that it is virtually impossible for unmeasured confounding to explain the association between firearms and suicide. The association is a real one.

Historically, the tobacco lobby claimed that the association between cigarettes and cancer could possibly be explained by some unknown risk factor for both. This assertion was finally refuted when scientists showed the absurd degree of association between both that such an unmeasured confounder would have to have. This article uses the same refutation for those who try to deny the causal association between guns and suicide.

Miller M, Swanson SA, Azrael D. Are we missing something pertinent? A bias analysis of unmeasured confounding in the firearm-suicide literature. Epidemiologic Reviews. 2016; 38(1):62-9.

The solicited commentary emphasizes the importance of the ecological studies of guns and suicide — that they overcome the “ecological fallacy.” The commentary also argues that ecological studies may be superior to case-control studies dealing with guns and homicide since men are usually shot outside the home with someone else’s gun. The commentary shows that there is strong ecological evidence of the gun-suicide connection in addition to the solid evidence from the case-control studies.

This commentary makes the case that the case-control studies analyzed in a recent meta-analysis provide only one part of the evidence that a gun in the home increases the risk of suicide. Adding ecological (and other) studies makes the case overwhelming.

Hemenway D. Guns, suicide, and homicide: Individual-level versus population-level studies (Commentary). Annals of Internal Medicine. 2014 Feb; 160:134-135.

This article describes the work HICRC has done over the past decade in finding common ground with gun owners to reduce firearm suicide. Gun owner groups are seen as part of the solution rather than part of the problem of suicide in America. Suicide is a gun owner’s issue–gun owning families are at higher risk for suicide. Partnerships among gun shop owners, firearm instructors, gun rights stakeholders and health professionals help to change social norms about guns and suicide, and can save lives.

Barber, Cathy; Frank, Elaine; Demicco, Ralph. Reducing suicides through partnerships between health professionals and gun owner groups–beyond docs vs glocks. JAMA-Internal Medicine. 2017; 177 (1):5-6.

While the overwhelming majority of firearms researchers and suicide experts agree that a gun in the home increases the risk of suicide, that knowledge has yet to reach the general population. HICRC’s national firearm survey finds that only 15% of Americans agree that the presence of a firearm in the home increases the risk for suicide, and only 30% of health care practitioners agree. Clearly more education about the scientific findings is needed.

Conner, Andrew; Azrael, Deborah; Miller, Matthew. Public opinion about the relationship between firearm availability and suicide: results from a national survey. Annals of Internal Medicine. 2018; 168(2):153-55.

This paper combines six known “facts” about suicide (e.g., households with firearms are at approximately 3x the risk of suicide as households without firearms) to reach six estimates not currently available in the literature such as: gun-owning households account for about 90% of all firearm suicides; some 75% of their suicides are firearm suicides, but only 20% of their suicide attempts are with firearms. Among non-owning households, only 1% of their suicide attempts are with firearms, but firearms account for 10% of their suicides. The reasonableness of these results provides support for the reasonableness of the half-dozen known “facts” about firearms and suicide.

Hemenway D. Comparing gun-owning vs non-owning households in terms of firearm and non-firearm suicide and suicide attempts. Preventive Medicine. 2019; 119:14-16.

Personal honor is associated with culturally defined honor-norms and its loss may predicate suicide. Reading the narratives from the National Violent Death Reporting System, we identified 163 honor-related suicides. Compared to the other 54,333 suicides in the database, honor-related suicides were more likely to write a suicide note, discuss suicidal intent, have criminal-legal problems, job and relationship problems, and suffer depression. Honor suicides are associated with public challenges to personal reputation.

Roberts K, Miller M, Azrael D. Honor-related suicide in the United State: A study of National Death Reporting System data. Archives of Suicide Research. 2019; 223:34-46.

We used NVDRS data 2005-2015, for the 13 states providing full data. Between 2005-2015 suicide rates by handguns, but not by long guns, increased in both urban and rural counties. Although handguns were used in nearly ¾ of firearm suicides for the total population, long gun use was relatively high in rural counties and among adolescents. Indeed, in rural counties, long guns were used in 51% of adolescent male suicides.

Hanlon TJ, Barber C, Azrael D, Miller M. Type of firearm used in suicides: findings from 13 states in the National Violent Death Reporting System, 2005-2015. Journal of Adolescent Health. 2019; 65:366-370.

We used data from Vital Statistics, National Emergency Departments, and Inpatient data to determine case fatality rates (CFR) for suicide (2007-2014).. Overall, 8.5% of suicide attempts were fatal (14.7% for males, 3.3% for females). The CFR was 3.4% of young people aged 15-24 and 35.4% for those 65+. Firearms were the most lethal (89.6%) followed by drowning (56.4%) and hanging (52.7%).

Conner A, Azrael D, Miller M. Suicide case fatality rates in the United States, 2007 to 2014: a nationwide population-based study. Annals of Internal Medicine. 2019; 171:885-895.

If fewer people in suicidal crisis have ready access to firearms, the US will see a reduction in its suicide rate. This article describes the emerging literature on community-based, firearm stakeholder engaged efforts to amplify key messages and normalize life-saving behaviors.

Henn M, Barber C, Hemenway D. Involving firearm stakeholders in community-based suicide prevention efforts. Current Epidemiology Reports. 2019; 6:231-237.

In California a cohort of 26 million residents—who had not previously acquired handguns– were followed up to 12 years. Over 675,000 acquired handguns, and these people were far more likely to die by suicide, because of their high rates of firearm suicide. More than half of all their suicides occurred more than a year

after firearm acquisition. They did not have higher rates of suicide by other means, or higher all-cause mortality.

Studdert DM, Zhang Y, Swanson SA, Prince L, Rhodden JA, Holsinger EE, Spittal MJ, Wintemute GJ, Miller M. Handgun ownership and suicide in California. New England Journal of Medicine. 2020; 382:2220-2229.

Other studies have shown that living in a home with guns is associated with higher rates of suicide (because of higher rates of firearm suicide). Could this difference in suicide rates be explained by their having more mental health problems? Data for this study come from a nationally representative sample of over 10,000 adolescents aged 13-18. 31% live in a home with guns, and the mental health characteristics of both groups (living and not living in a home with guns) are similar.

Swanson S, Eyllon M, Sheu Y, Miller M. Firearm access and adolescent suicide risk: Toward a clearer understanding of effect size. Injury Prevention. 2020; 27:264-270.

This short commentary discusses that the limited evidence suggests there should not be large second-order effects on non-firearm suicide—due to lethal substitution or contagion—of policies that might reduce firearm suicide.

Azrael D, Miller M. Access to firearms, homicide, and suicide: role of the mortality multiplier. American Journal of Public Health. 2020; 110:1456-1457.

Using linked Utah data, most suicide deaths were firearm deaths. Among 56 people who survived a firearm attempt, none subsequently died by suicide during the study period.

Thomas NM, Barber C, Miller M. A cohort study of initial self-harm events: method-specific case fatality of index events, predictors of fatal and non-fatal repetition, and frequency of method-switching. International Review of Psychiatry. 2021; 33:598-606.

Using NVDRS data from 2004-2015, we text searched over 63,000 firearm suicides for those occurring at public shooting ranges. We estimate that 35 such suicides occur each year. When gun ownership was noted, 86% of the guns were rented from the range. Some ranges have adopted policies, such as allowing rentals only if the person is not alone, that are responsive to the actual characteristics of these deaths can could potentially prevent most.

Barber C, Walters H, Brown T, Hemenway D. Suicides at gun ranges. Crisis. 2021; 42:13-19.

Using linked data from Utah, we found that 19% of non-firearm suicide decedents had visited a hospital for deliberate self-harm, and 55% for any behavioral health issue (substance abuse, mental health, self-harm). Firearm suicide decedents respective numbers were 8% and 41%. Hospital-based interventions to prevent suicide should not be limited to visits for self-harm.

Berrigan J, Miller M, Zhang W, Azrael D, Barber C. Hospital visit histories of suicide decedents: a study in Utah. Injury Prevention. 2022; 28:259-261.

Using National Violent Death Reporting System (NVDRS) data for 2015-2017, we found that among firearm suicides, 88% of adult males used their own gun, 52% of adult women used their own gun; and 42% of youth aged 18-20 used their own gun. Different methods are required for these three groups if the goal is to reduce quick access to a firearm among those at-risk.

Barber C, Azrael D, Miller MJ, Hemenway D. Who owned the gun in firearm suicides of men, women and children in five US states? Preventive Medicine. 2022; 164:107066

Data come from our 2019 National Firearm Survey, with responses from more than 2,500 firearm owners.

Andrew Conner, Azrael D, Miller M. Perceptions of firearm accessibility and suicide among US adults living in household with firearms. JAMA Network Open. 2022; 5:32239278.

Using linked data, we examined the suicide decedents who worked in Construction/Extraction in Utah. Two thirds of the males had a substance abuse problem, 48% were reported to have intimate partner problems, 26% had criminal problems and 25% were unemployed.

Henn M, Barber C, Zhang W, Staley M, Azrael D, Miller M. Identifying occupation groups for suicide prevention: a statewide data linkage study. Archives of Suicide Research. 2023; 27:494-504.

Using longitudinal data from over 500,000 handgun owners from California, this study compares owners who got rid of their guns vs owners who didn’t. Divestment appeared to reduce firearm suicide by 50%, and controlling for other factors, also reduce total suicide risk.

Swanson SA, Studdert DM. Yifan Zhang, Prince L, Miller M. Handgun divestment and risk of suicide. Epidemiology. 2023; 34:99-106.