September is Suicide Prevention Awareness Month. During this month, you’ll undoubtedly hear messages about the need to talk about suicide, reduce stigma around mental illness, and seek help through suicide hotlines (1-800-273-8255) and professional services. You may also hear about innovative programs to prevent suicide with better screening in healthcare settings and referral to mental health services, such as the Zero Suicide model. All of this is important and necessary work, which we should have started doing long ago, and to which we are fortunately paying ever greater attention and devoting growing resources. But in all of these discussions about suicide, how often will the politically radioactive topic of guns in the United States come up? My bet is that it will come up only occasionally, usually as only a side bar, and not nearly often enough. The reality is that gun safety should be central to suicide prevention, and politics is the main factor that keeps us away from the subject.
Our avoidance of talking about and coming up with solutions for gun violence is deadly. Despite the increasing attention on suicide prevention, it stubbornly remains a leading cause of death in the United States; it is the second leading cause of death for adolescents and suicide rates are highest in people ages 45 to 55. In fact, the Centers for Disease Control and Prevention (CDC) recently reported that suicides increased substantially between 1999 and 2016. During this period, suicide rates increased in every state but Nevada, and suicide rates went up by more than 30% in half of states. In 2016, nearly 45,000 people died by suicide in the United States, substantially more than died in motor vehicle accidents.
Why are suicide deaths growing even as we devote more resources to preventing them? Part of it is that suicide remains a rare event, with widely varying causes and precipitating factors, which makes it extremely difficult to predict and prevent. For instance, even though mental illness is a well-established risk factor for suicide, more than half of people who die by suicide in the United States don’t have a known mental illness, so it’s no wonder interventions within the mental health system have only limited effects. Part of the difficulty is also that we don’t yet have many proven interventions to effectively reduce suicidal thinking, even when we do find out about it. But one of the biggest challenges is that we are allergic as a society to talking about – never mind addressing – our gun crisis.
In 2016, more than half of the 44,965 suicides in the United States were by firearms, and almost 60% of the 38,658 gun-related deaths were suicides . There is a strong and consistent association between access to firearms and suicide rates. Demographic groups with higher gun ownership rates (e.g., white men) have higher suicide rates; states (e.g., in the South and West) and regions (i.e., rural) with higher gun ownership rates have higher suicide rates; and people living in households with guns have a higher risk of suicide.
Why is there such a strong correlation between gun availability and suicide? Contrary to some popular belief, suicide is not often a carefully considered, well-planned decision. Rather, it is often a highly impulsive act, carried out amidst crisis, fueled by a toxic mix of anger and alcohol or drugs. Therefore, the lethality of the means used in the suicide attempt is key to whether the person will die or survive to get the help they need. Having a gun within easy reach can very quickly turn a manageable crisis into an irreversible tragedy. This is because guns have by far the highest fatality rate, resulting in death in 80-90% of suicide attempts, while hanging results in death in roughly 60% of attempts, and overdose is lethal in less than 2% of cases. People who survive a suicide attempt are not likely to substitute more lethal means in another attempt; in fact, only about 7% of these individuals eventually go on to die by suicide. This phenomenon is the reason that while men attempt suicide at lower rates than women in the United States, they die by suicide at higher rates; it’s because they are more likely to use lethal means, particularly guns.
So, what can we do to solve our suicide-by-gun crisis in the United States? The single most effective public health solution for firearm-related suicide – and likely even suicide overall – would be to reduce the availability of guns within the population. We know that “lethal means restriction” works for suicide prevention. For instance, studies on barriers to prevent people from jumping off bridges show sustained, community-wide reductions in suicide rates – once impulsive acts are thwarted, most would-be suicide victims do not simply find other places from which to jump. It stands to reason that removing guns from potential crises could work in much the same way. In fact, there is striking evidence that this is true. For example, citing suicide as a major cause of death in soldiers, the Israeli Defense Force changed its policy in 2006 to require that soldiers leave their guns on the base when they went home on weekends. This policy change correlated with a 40% drop in annual suicides among soldiers, with the entire decrease attributable to a reduction in suicides on the weekends.
While population-wide reductions in firearm availability are likely to have the largest public health impact, restricting gun access for only the highest risk individuals can also save lives. The best example of policies that can achieve this are Extreme Risk Protection Orders (ERPOs), also called Gun Violence Prevention Restraining Orders. ERPOs allow family members, household members, police officers, or district attorneys (and some allow school officials) to petition a court to temporarily remove firearms from an individual’s possession when they exhibit signs that they might be a danger to themselves or others. Preliminary evidence suggests that ERPOs are effective in reducing firearm-related and overall suicide rates.
Unfortunately, for the time-being, politics has largely won out over good sense in the United States, and we are unable to talk about or even study ways of reducing access to guns on a population level, let alone actually start doing it. So, we continue to talk about suicide and ways to prevent it every September without getting at the heart of the matter, and suicide rates continue to increase, leaving an alarming toll of death and grief in its wake. However, there are still things that individual clinicians, family members, and community members can do to reduce the burden of gun-related suicide. First, we should ask about gun ownership, because you can’t reduce a risk that you don’t know about. Healthcare professionals should ask their patients, parents should ask other parents before allowing their children to go on a play date, and everyone should ask their loved ones about gun access. Second, when you find out someone owns a firearm, you should advise them about safe storage. There are resources to help you know what to tell them. Finally, for those who may be in crisis and have access to a gun, we must do everything we can to try to temporarily restrict their access to those weapons. ERPOs can help, but many local police departments also have voluntary safe storage programs. Or maybe you can convince the person to move the guns to a safe location in a trusted loved one’s home.
Many people are working hard to develop effective public health and clinical interventions to prevent suicide. We must continue to support them in their efforts, and hope that they see increasing success. However, in the United States today, the single most effective public health approach to begin reversing the trend of rising suicides would be to vigorously address our gun crisis. But to do this, we first need to be able to talk about it openly and rationally. For the sake of our families, friends, and communities, let’s hope we can start doing that soon.
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