Effects of restrictive licensing of handguns on homicide and suicide in the District of Columbia

Firearm availability and suicide, homicide, and unintentional firearm deaths among women

CONTEXT

In the United States, more than 45,000 women died from gun violence over the last decade.

OBJECTIVE

To determine whether measures of firearm availability are related to rates of suicide, homicide, and unintentional firearm deaths among women in the United States.

DESIGN

Pooled cross-sectional time series data on suicide, homicide, and unintentional firearm deaths (1988-1997) were used to estimate the association between the rate of violent death among women and four proxies of firearm availability. Two proxies came from survey reports of household firearm ownership rates; two were derived from mortality statistics.

SETTING

United States, 1988-1997.

RESULTS

The increased rate of suicide and homicide in states with high gun levels was accounted for primarily by significantly elevated firearm suicide and firearm homicide rates. Unintentional firearm death rates were also increased in states with more guns. At the regional level, qualitatively similar results were obtained.

CONCLUSION

Between 1988 and 1997, the suicide, homicide, and unintentional firearm death rates among women were disproportionately higher in states where guns were more prevalent. The elevated rates of violent death in states with more guns was not entirely explained by a state's poverty or urbanization and was driven primarily by lethal firearm violence, not by lethal nonfirearm violence.

Firearm availability and unintentional firearm deaths, suicide, and homicide among 5-14 year olds

BACKGROUND

In the United States, only motor vehicle crashes and cancer claim more lives among children than do firearms. This national study attempts to determine whether firearm prevalence is related to rates of unintentional firearm deaths, suicides, and homicides among children.

METHODS

Pooled cross-sectional time-series data (1988-1997) were used to estimate the association between the rate of violent death among 5-14 year olds and four proxies of firearm availability, across states and regions.

RESULTS

A statistically significant association exists between gun availability and the rates of unintentional firearm deaths, homicides, and suicides. The elevated rates of suicide and homicide among children living in states with more guns is not entirely explained by a state's poverty, education, or urbanization and is driven by lethal firearm violence, not by lethal non-firearm violence.

CONCLUSION

A disproportionately high number of 5-14 year olds died from suicide, homicide, and unintentional firearm deaths in states and regions where guns were more prevalent.

Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. American Academy of Child and Adolescent Psychiatry

These guidelines review what is known about the epidemiology, causes, management, and prevention of suicide and attempted suicide in young people. Detailed guidelines are provided concerning the assessment and emergency management of the children and adolescents who present with suicidal behavior. The guidelines also present suggestions on how the clinician may interface with the community. Crisis hotlines, method restriction, educational programs, and screening/ case-finding suicide prevention strategies are examined, and the clinician is advised on media counseling. Intervention in the community after a suicide, minimization of suicide contagion or imitation, and the training of primary care physicians and other gatekeepers to recognize and refer the potentially suicidal child and adolescent are discussed.

Firearms and suicide

The evidence linking firearms in the home to risk for suicide is reviewed. These data come from epidemiological, case-control, quasiexperimental, and prospective studies. The convergent finding from this wide range of studies is that there is a strong relationship between firearms in the home and risk for suicide, most firmly established in the United States.

[Health behavior among students of public and private schools in the metropolitan area of São Paulo, Brazil]

OBJECTIVE

To investigate the prevalence of several health behaviors among students of public and private schools in S. Paulo, Brazil.

METHODS

An epidemiological survey about health behaviors among high school students was carried out in S. Paulo in 1998. Seventh to eleventh graders from ten public and seven private schools were interviewed. All students were asked to fill out a Portuguese version of the questionnaire used by the Centers for Disease Control and Prevention in their annual "Youth Health Risk Behavior Survey". This questionnaire includes questions on driving-related behavior, violence, substance abuse, sexual practices, dietary habits and body weight control.

RESULTS

A significant proportion of the students, mainly in the range of 15--18 years old, reported engaging in health-risk behaviors. In public schools, the most prominent risk behaviors were: riding a motorcycle without helmets (reported by 70.4% of the students who were either passengers or the driver); not using condoms in the last sexual intercourse (34% among those sexually active); carrying guns (4.8% in the last year), and suicide attempts (8.6% in the last year). In private schools, substance abuse was the most prominent risk-behavior: 25% reported at least one episode of binge-drinking in the last 30 days, 20.2% sniffed solvents at least once in the last year and 22.2% smoked marijuana in the same period; 13.8% reported using tobacco on a regular basis. Not wearing helmets while riding a motorcycle was also very high, reported by 66.3%. Female students reported less risk-behaviors, except for suicide attempts and unhealthy weight control methods.

CONCLUSIONS

The information gathered could contribute to the development of preventive programs at school level, which takes into consideration the students' risk behaviors.

Intentional injuries among the young: presentation to emergency rooms, hospitalization, and death in Israel

PURPOSE

To study the incidence and outcome of intentional injuries requiring emergency room (ER) care among children and adolescents in a national sample.

METHOD

The population included 0- to 17-year-olds who presented to the ER for injuries in 23 hospitals over a 1-year period. A 6% to 9% random sample of days was selected in each hospital, and for each selected day the relevant ER record was reviewed for cause, nature, and outcome of injuries and sociodemographic information.

RESULTS

The annual incidence for intentional injuries resulting in ER visits was 19.6 in 10,000 children and adolescents aged 0 to 17 [95% confidence interval (CI) 17.4-21.8 in 10,000]. Fights/assaults constituted 54.1% of the presentations, abuse and rape, 10.3%, and self-inflicted injuries, 10.8%. Overall rates were higher among 10- to 17 year olds than at younger ages. The rates were higher among boys than girls for fights/assaults and abuse, whereas attempted suicide and rape were three times higher among girls than boys. Nearly twice as many Jewish children and adolescents presented to the ER for intentional injuries than Arab children and adolescents, with the ratio becoming even greater for attempted suicide. Of all the intentionally injured, 21.7% were hospitalized. The mortality rate was 1.1 in 100,000 (95% CI =.7-1.7/100,00) with no significant gender difference observed. No cases of suicide were reported for the Arab population.

CONCLUSIONS

Adolescents aged 10 years and older are at higher risk for intentional injuries than younger children. The ethnic differences evident in this study, especially for attempted and completed suicide, may be real or the result of differential disclosure of information owing to sociocultural norms or differential recording by health professionals.

Suicide acts in 8 states: incidence and case fatality rates by demographics and method

OBJECTIVES

This study examined incidence rates of medically identified suicide acts (self-inflicted injuries, either fatal or nonfatal) and case fatality rates by age, sex, race, and method used.

METHODS

The authors analyzed data on 10,892 suicides and 57,439 attempted suicides among hospital-admitted individuals in 8 states, along with 6219 attempted suicides among individuals released from emergency departments in 2 states.

RESULTS

The 8 states experienced a mean of 11 suicides and 119 attempted suicides per 100,000 residents each year. Groups with high suicide rates were men, the elderly, and Whites; groups with high attempted suicide rates were teenagers, young adults, women, and Blacks and Whites aged 25 to 44 years. Blacks aged 15 to 44 years evidenced high attempted suicide rates undocumented in previous studies. Poisoning and firearm were the most common methods used among those attempting suicide and those completing suicide acts, respectively. The most lethal method was firearm.

CONCLUSIONS

The characteristics of suicides and attempted suicides differ dramatically. Method used is important in the lethality of the act.

Compliance with recommendations to remove firearms in families participating in a clinical trial for adolescent depression

OBJECTIVE

To assess the rate and correlates of compliance with clinicians' recommendations to remove firearms from the homes of depressed adolescents participating in a clinical trial.

METHOD

The parents of 106 adolescents with major depression who participated in a randomized psychotherapy clinical trial were asked systematically about firearms in the home. Those who answered affirmatively were given information about the suicide risk conveyed by guns in the home and urged to remove them. The rates of gun removal and acquisition were assessed at the end of the treatment and over the subsequent 2-year naturalistic follow-up.

RESULTS

Of those who had guns at intake, 26.9% reported removing them by the end of the acute trial. Retention was associated with urban origin, marital dissatisfaction, and paternal psychopathology. Of those who did not have guns at intake, 17.1% reported acquiring them over 2-year follow-up. Living in a 2-parent household and marital dissatisfaction were associated with gun acquisition.

CONCLUSIONS

Families of depressed adolescents may frequently be noncompliant with recommendations to remove guns from the home despite compliance with other aspects of treatment. More efficacious interventions to reduce access to guns in the homes of at-risk youths are needed.

Structural interventions in public health

OBJECTIVE

To review structural interventions in public health, identify distinct approaches to structural interventions, and assess their implications for HIV-prevention interventions.

METHOD

The MEDLINE, HealthStar, PsychInfo and Sociofile databases were searched on specific health issues, types of public health interventions, and conceptual topics (e.g. empowerment, social structure, and inequality) to compile a list of public health interventions in the United States. We excluded interventions focused on testing and surveillance unless they specifically facilitated prevention, and educational or media campaigns focused on increasing individuals' level of knowledge about a particular health problem.

RESULTS

The term 'structural' is used to refer to interventions that work by altering the context within which health is produced or reproduced. Structural interventions locate the source of public-health problems in factors in the social, economic and political environments that shape and constrain individual, community, and societal health outcomes. We identified two dimensions along which structural interventions can vary. They may locate the source of health problems in factors relating to availability, acceptability, or accessibility; and they may be targeted at the individual, organizational, or environmental levels. All together, this framework suggests nine kinds of structural interventions, and it is possible to identify examples of each kind of intervention across a range of public health issues.

CONCLUSIONS

The relevance of this framework for developing HIV prevention interventions is considered.

Preventive interventions for youth suicide: a risk factor-based approach

OBJECTIVE

This review draws on current knowledge of risk for youth suicide to categorize strategies for intervention. Its goal is to identify areas of 'research need' and to provide an evidence base to identify 'best buy' preventive interventions for youth suicide.

METHOD

The design, development, implementation and evaluation of prevention strategies ranging from clinical interventions to population-based universal approaches are considered within five risk factor domains: individual, family, community, school and peer.

RESULTS

There is a paucity of evidence on the effects of interventions targeting depression and suicidal behaviour. Nevertheless, there are effective indicated, selective and universal interventions for important risk factors for depression and suicidal behaviour. Little evidence has emerged to support the efficacy of some traditional approaches to suicide prevention, such as school based suicide education programs and telephone hotlines.

CONCLUSIONS

Youth suicide prevention strategies in Australia have generally employed traditional approaches that focus on clinical interventions for self-harmers, restricting access to lethal means, providing services to high risk groups and enhancing general practitioner responses. Both program development and research evaluation of interventions for many important risk and protective factors for suicide have been neglected.

Child and adolescent suicide deaths in New Mexico, 1990-1994

The suicide death rate in New Mexico is consistently higher than the national rate. Among adolescents, suicide is the third leading cause of death nationally, but in New Mexico it is the second leading cause of death. This study describes the pattern of adolescent suicide deaths in New Mexico. We conducted a retrospective review of all medical examiner autopsies for adolescent suicides (ages 20 years and younger) in New Mexico from 1990-1994. Records were reviewed for demographics and possible contributing factors such as depression, previous attempts, and alcohol and drug use. We identified 184 suicide deaths among children and adolescents ages 9-20 years for an overall rate of 12.9 per 100,000. Our rates for ages 5-9 years (0.2), 10-14 years (3.8), and 15-19 years (22.3) are over twice the U. S. rates. Suicide deaths resulted primarily from firearms (67%), hanging (16%), poisoning (6%), inhalation (4%), and other methods (7%). Method varied by ethnicity (p = .01) and gender (p = .03); males and non-Hispanic Whites were overrepresented among firearm deaths. Firearm ownership was known in 60 (48%) of the firearm deaths. Of these, 53% of the firearms belonged to a family member, 25% to the decedent, and 22% to a friend. Over one-third of decedents (41%) experienced mental disorders, primarily depressed mood and clinical depression. Previous suicide attempts were noted for 15% of the decedents. Some 50% of the decedents had alcohol or drugs present at the time of death; among American Indians/Alaska Natives, 74% had drugs or alcohol present (p = .003). Targeted interventions are needed to reduce adolescent suicide in New Mexico. We suggest raising awareness about acute and chronic contributing factors to suicide; training physicians to look for behavioral manifestations of depression; and involving physicians, teachers, and youth activity leaders in efforts to limit firearm accessibility, such as advising parents to remove firearms from their households.

Policy evaluation research. Measuring the independent variables

The purpose of this article is to evaluate the accuracy of three methods used to obtain policy data: (a) government agency surveys, (b) secondary sources, and (c) historical legal research. Changes in laws were identified for all 48 contiguous states for the period 1968 to 1994. Legal research is most accurate for well-established laws that have consistent legal descriptions across nearly all states. Laws that are recently enacted, adopted by only a few states, and treated in a legally inconsistent manner across states require a multistage data collection method to identify accurate policy change information.

Beliefs about the risks of guns in the home: analysis of a national survey

OBJECTIVES

While epidemiological evidence suggests homes with guns are more likely to be the site of a suicide or homicide than homes without guns, the public's perception of these risks remains unknown. This study assesses the prevalence of the belief that homes with guns are safer than homes without guns, and factors associated with this belief.

METHODS

Telephone interviews were conducted with a random sample of 4138 registered voters in urban areas in the US. Multinomial logistic regression was used to assess correlates of beliefs about the safety of keeping a gun in the home.

RESULTS

Twenty nine per cent of respondents believed keeping a gun in the home makes the home more safe, 40% said less safe, 23% said it depends, and 9% were unsure. The belief that a home is more safe with a gun was associated with being male, young, completing 12 years or fewer of education, having no children living at home, Republican party affiliation, and low levels of trust in the police for protection. Prior exposure to violence and fear of victimization were not associated with the outcome.

CONCLUSIONS

Findings may increase understanding about the public's perception of the risk in keeping guns in the home and assist educational efforts to decrease the risk of these injuries.

Effects of Maryland's law banning Saturday night special handguns on crime guns

OBJECTIVES

To determine the effects of a 1988 Maryland law that banned "Saturday night special" handguns on the types of guns used in crime. To determine if controls on the lawful market for handguns affect the illegal market as well.

SETTING

Baltimore, Maryland, and 15 other US cities participating in a crime gun tracing project.

METHODS

Cross sectional comparison of the proportion of crime guns that are banned by the Maryland law, comparing Baltimore, MD with 15 other cities outside of Maryland. Multivariate linear regression analysis to determine if observed differences between Baltimore and 15 other cities are explained by demographic or regional differences among the cities rather than Maryland's law.

RESULTS

Among crime guns, a gun banned by Maryland's law is more than twice as likely (relative risk (RR) 2.3, 95% confidence interval (CI) 2.0 to 2.5) to be the subject of a crime gun trace request in 15 other cities combined, than in Baltimore. Among homicide guns, a crime especially relevant for public safety, a comparable difference (RR 2.1, 95% CI 1.1 to 4.2) was observed. The proportion of Baltimore's crime guns that are banned is 12 percentage points lower than would be expected based on its demographic and regional characteristics alone. Among crime guns purchased after 1990, a much smaller proportion in Baltimore are banned models than in 15 other cities.

CONCLUSIONS

Maryland's law has reduced the use of banned Saturday night specials by criminals in Baltimore. Contrary to the claims of some opponents of gun control laws, regulation of the lawful market for firearms can also affect criminals.

Mortality among recent purchasers of handguns

BACKGROUND

There continues to be considerable controversy over whether ownership of a handgun increases or decreases the risk of violent death.

METHODS

We conducted a population-based cohort study to compare mortality among 238,292 persons who purchased a handgun in California in 1991 with that in the general adult population of the state. The observation period began with the date of handgun purchase (15 days after the purchase application) and ended on December 31, 1996. The standardized mortality ratio (the ratio of the number of deaths among handgun purchasers to the number expected on the basis of age- and sex-specific rates among adults in California) was the principal outcome measure.

RESULTS

In the first year after the purchase of a handgun, suicide was the leading cause of death among handgun purchasers, accounting for 24.5 percent of all deaths and 51.9 percent of deaths among women 21 to 44 years old. The increased risk of suicide by any method among handgun purchasers (standardized mortality ratio, 4.31) was attributable entirely to an excess risk of suicide with a firearm (standardized mortality ratio, 7.12). In the first week after the purchase of a handgun, the rate of suicide by means of firearms among purchasers (644 per 100,000 person-years) was 57 times as high as the adjusted rate in the general population. Mortality from all causes during the first year after the purchase of a handgun was greater than expected for women (standardized mortality ratio, 1.09), and the entire increase was attributable to the excess number of suicides by means of a firearm. As compared with the general population, handgun purchasers remained at increased risk for suicide by firearm over the study period of up to six years, and the excess risk among women in this cohort (standardized mortality ratio, 15.50) remained greater than that among men (standardized mortality ratio, 3.23). The risk of death by homicide with a firearm was elevated among women (standardized mortality ratio at one year, 2.20; at six years, 2.01) but low among men (standardized mortality ratio at one year, 0.84; at six years, 0.79).

CONCLUSIONS

The purchase of a handgun is associated with a substantial increase in the risk of suicide by firearm and by any method; the increase in the risk of suicide by firearm is apparent within a week after the purchase of a handgun. The magnitude of the increase and the relation between handgun purchase and the risk of death by homicide differ between men and women.

Effectiveness of denial of handgun purchase to persons believed to be at high risk for firearm violence

OBJECTIVES

The purpose of this study was to determine whether denial of handgun purchase is an effective violence prevention strategy.

METHODS

Individuals denied handgun purchase because of a prior felony conviction and handgun purchasers with a felony arrest at time of purchase were examined.

RESULTS

Relative to those denied purchase, handgun purchasers were found to be at greater risk for subsequent offenses involving a gun (relative risk [RR] = 1.21, 95% confidence interval [CI] = 1.08, 1.36) or violence (RR = 1.24, 95% CI = 1.11, 1.39), after adjustment for number of prepurchase weapon/violence charges.

CONCLUSIONS

Denial of handgun purchase to persons with a prior felony conviction may lower their rate of subsequent criminal activity.

Attitudes toward suicide among South African secondary school pupils

This study investigated attitudes towards suicide among 622 Standard 9 (U.S. Grade 11) secondary school pupils chosen at random from schools throughout the Northern Province in South Africa. The pupils were 254 (41%) boys and 368 (59%) girls in the age range of 17 to 24 years, with a mean age of 19.3 yr. A questionnaire was administered to obtain data on attitudes and other measures. There were 31 (17%) parasuicidal boys and 34 (13%) girls. Major intentions or reasons to commit suicide mentioned were "failing to solve problems" and "mental illness." Most frequent possible suicide methods were firearms, pills, or poison. Significant associations were found with having a friend or relative who committed suicide, parasuicide (oneself), depression, stress events, ethnicity, and attitudes towards suicide.

Support for new policies to regulate firearms. Results of two national surveys

BACKGROUND

New policy options are emerging in the debate regarding the regulation of firearms in the United States. These options include the treatment of firearms as consumer products, the design of which can be regulated for safety; denial of gun ownership to those convicted of misdemeanors; and strategies to curtail the illegal sale of guns. The public's opinion of these innovative gun-policy options has not been thoroughly assessed.

METHODS

We conducted two telephone surveys of 1200 adults each in the United States in 1996 and 1997-1998. Cognitive interviews and pretests were used in the development of the survey instruments. Potential participants were then contacted by random-digit dialing of telephone numbers.

RESULTS

A majority of the respondents favored safety standards for new handguns. These standards included childproofing (favored by 88 percent of respondents), personalization (devices that permit firing only by an authorized person; 71 percent), magazine safeties (devices that prevent firing after the magazine or clip is removed; 82 percent), and loaded-chamber indicators (devices that show whether the handgun is loaded; 73 percent). There was strong support for policies prohibiting persons convicted of specific misdemeanors from purchasing a firearm. Support for such prohibitions was strongest for crimes involving violence or the illegal use of a firearm (83 to 95 percent) or substance abuse (71 to 92 percent). There was also widespread support for policies designed to reduce the illegal sale of guns, such as mandatory tamper-resistant serial numbers (90 percent), a limit of one handgun purchase per customer per month (81 percent), and mandatory registration of handguns (82 percent). Even among the subgroup of respondents who were gun owners, a majority were in favor of stricter gun regulations with regard to 20 of the 22 proposals covered in the poll.

CONCLUSIONS

Strong public support, even among gun owners, for innovative strategies to regulate firearms suggests that these proposals warrant serious consideration by policy makers.

Trends in nonfatal and fatal firearm-related injury rates in the United States, 1985-1995

STUDY OBJECTIVE

To characterize trends in annual estimates of nonfatal firearm-related injuries treated in US hospital emergency departments and to compare trends in quarterly rates of such injuries with those of firearm-related fatalities in the US population.

METHODS

Data on nonfatal firearm-related injuries were obtained from the National Electronic Injury Surveillance System (NEISS) by review of medical records for June 1, 1992, through May 31, 1995. Data on firearm-related fatalities were obtained from the National Vital Statistics System for January 1, 1985, through December 31, 1995. NEISS comprises 91 hospitals that represent a stratified probability sample of all hospitals in the United States and its territories that have at least six beds and provide 24-hour emergency service. The main outcome measures were numbers, percentages, and quarterly population rates for nonfatal and fatal firearm-related injuries.

RESULTS

An estimated 288,538 nonfatal firearm-related injuries (95% confidence interval [CI], 169,776 to 407,300) were treated in EDs during the 3-year study period. The annual number of non-fatal firearm-related injuries increased from 99,025 for June 1992 through May 1993 (95% CI, 58,266 to 139,784) to 101,669 for June 1993 through May 1994 (95% CI, 59,822 to 143,516), then decreased to 87,844 for June 1994 through May 1995 (95% CI, 51,687 to 124,001). Before the third quarter of 1993, quarterly nonfatal and fatal firearm-related injury rates in the total US population and quarterly nonfatal firearm assaultive injury and firearm homicide rates for males aged 15 to 24 years were observed to be on the rise. Since then, these rates have significantly declined.

CONCLUSION

Analysis of national trends indicates that non-fatal and fatal firearm-related injuries are declining in the United States, although the rate of firearm-related deaths remains high, especially among males aged 15 to 24 years, in relation to other leading causes of injury death. An assessment of factors responsible for the decline in firearm-related injuries is needed to design further prevention efforts.

Evaluation of interventions to prevent injuries: an overview

Overview of issues involved in evaluating the effectiveness of injury interventions is presented. An intervention should be evaluated to show it prevents injuries in the target population, to identify unintended consequences, to correct problems that limit effectiveness, to justify current and future resources from funding agencies, and to guide its replication elsewhere. Problems in conducting evaluations include obtaining sufficient resources, coping with rare events, establishing reliability and validity of measurement instruments, separating effects of multiple simultaneous events, and adjusting for the time lag between an intervention and its effects. When feasible, changes in injury rates (documented by medical records) should be used. These are more convincing for demonstrating intervention effectiveness than changes in observed or reported behaviors or in knowledge and attitudes (documented by surveys). Quasiexperimental evaluation designs are often useful, such as measuring injury rates before and after an intervention in a time series design, or intervening in one of two comparable communities in a nonequivalent control group design. Evaluations using true experimental designs, in which individuals or groups are randomized to receive or not receive an intervention, are highly desirable but are often difficult due to logistical or ethical considerations. An evaluation component should be integral to the introduction of any new injury intervention.

Firearm suicides and homicides in the United States: regional variations and patterns of gun ownership

Among industrialized countries, the United States has the highest rates of firearm suicide and homicide, as well as the highest rate of gun ownership. The present study compares the differential impact of gun availability on firearm suicides and homicides in the U.S. Using data from the NCHS Mortality Detail Files (1989-1991), the 1990 U.S. census population estimates, and the General Social Surveys (1989-1991) for nine geographic divisions, we computed rates of firearm and non-firearm suicides and homicides as well as rates of gun ownership for four gender-race groups. We tested the strength of the associations between gun availability and firearm suicide and homicide rates by computing the Spearman correlation coefficients. To help elucidate the role of method substitution, we conducted similar analyses on non-firearm suicide and homicide. The results show that gun ownership has a stronger impact on firearm suicides than homicides. These findings held up after stratifying by gender and race. The study suggests that reducing the aggregate level of gun availability may decrease the risk of firearm-related deaths.

Adolescent suicide

This article reviews the origin of youth suicide. Theoretic suicide risk factors and empirically observed suicide risk factors are discussed along with proposed resiliency factors that prevent suicide. Finally, suicide prevention and intervention strategies are covered, and a call for better studies on suicide prevention is heralded.

Prevention of firearm-related injuries and deaths among youth. A product-oriented approach

Firearm-related injuries are the second leading cause of death in youth. A product-oriented approach, focusing on the gun, may be an efficient and effective strategy to reduce firearm-related injuries and death. Such an approach includes decreasing the number of guns in the environment and modifying the gun to reduce it potential for harm. As with efforts to reduce childhood injuries from motor vehicle crashes and poisonings, pediatric health professionals can assume a leadership role in preventing firearm-related injuries and death in youth.

An update on the impact of gun control legislation on suicide

OBJECTIVE

The authors review recent literature examining the impact of gun control legislation on suicide rates.

METHOD

MEDLINE and PsychLIT searches on gun ownership, gun control, and psychiatric firearm-related topics from 1982 through March 1997 were examined for reports focusing on gun control legislation and suicide.

RESULTS

Suicide rates typically decreased following implementation of a variety of firearm control laws. Suicide-prone individuals seldom substitute other means or go outside legal channels for suicide weapons. Firearm restrictions may decrease the ready accessibility of firearms enough to allow the peak period of suicidality to pass.

CONCLUSION

The findings support gun control measures as a strategy for reducing suicide rates.

Hunting guns in homes and suicides in 15-24-year-old males in eastern Finland

OBJECTIVE

The aim of this study was to investigate the associations between firearm ownership, the presence of guns in homes, the use of psychiatric services and suicides in 15-24-year-old males in Eastern Finland.

METHOD

Police and medicolegal records of all suicides (n = 68) performed by 15-24-year-old males in the Kuopio province, Eastern Finland, in 1988-1995 were studied. Information was sought about firearm ownership, legality and purposes of use. Information was also sought about recent contacts with psychiatric services. Firearm suicides were compared with suicides by other methods.

RESULTS

The annual suicide rate for 15-24-year-old males was 51/100 000. Sixty-two percent of suicides were committed by shooting. In 74% of these, licensed hunting guns were used. The proportion of suicides committed by legal hunting guns stored in the homes of victims was 60% of all firearm suicides. Sixty-two percent of firearm suicides were committed in homes of victims or in someone else's residence where guns were present. Only 2% of those who shot themselves were seen in psychiatric consultation during the 3 months prior to death.

CONCLUSIONS

The presence of hunting guns in homes means easy access to a most lethal suicide method and is associated with a high suicide rate for 15-24-year-old males in Eastern Finland.

Management of suicidal behavior in the elderly

Suicidal behavior in older people is more often lethal than in any other age group. Social isolation, losses and physical illness, a past history of suicide attempts, and psychiatric illness are risk factors with implications for prevention of late life suicide. Preliminary indications are that community outreach to elders at risk and educational programs for primary care providers on the identification and treatment of late life depression are effective at lowering suicide rates.

A quarter century of violence in the United States. An epidemiologic assessment

During the past quarter century violence consistently has been a major problem in the United States. During this period, the profile of violence has changed. Adolescent and young adults are assuming a substantially greater role in serious and fatal violent events. The increased use of firearms, particularly by male youth and young adults, has rendered their acts of violence more lethal.

Costs of gunshot and cut/stab wounds in the United States, with some Canadian comparisons

This article estimates the costs of U.S. gunshot and cut/stab wound by intent. It also compares U.S. to Canadian gunshot experience. Incidence data are from published sources, the National Hospital Ambulatory Medical Care Survey (NHAMCS), and cause-coded emergency department discharge and hospital discharge data systems. Medical care payments and lost earnings per case come from National Crime Survey data, a literature review, and weighting of costs by diagnosis from Databook on Nonfatal Injury-Incidence. Costs, and Consequences by Miller et al. (The Urban Institute Press, Washington, DC. 1995) with the diagnosis distribution of penetrating injuries from the discharge data systems. Quality of life losses are estimated primarily from jury awards to penetrating injury victims. In 1992, gunshots killed 37,776 Americans; cut/stab wounds killed 4095. Another 134,000 gunshot survivors and 3,100,000 cut/stab wound survivors received medical treatment. Annually, gunshot wounds cost an estimated U.S. $126 billion. Cut/stab wounds cost another U.S. $51 billion. The gunshot and cut/stab totals include U.S. $40 billion and U.S. $13 billion respectively in medical, public services, and work-loss costs. Across medically treated cases, costs average U.S. $154,000 per gunshot survivor and U.S. $12,000 per cut/stab survivor. Gunshot wounds are more than three times as common in the U.S. than in Canada, which has strict handgun control. With the same quality of life loss per victim, gunshot costs per capita are an estimated U.S. $495 in the U.S. vs U.S. $180 in Canada. Per gun, however, the costs are higher in Canada, Gunshot wound rates rise linearly with gun ownership.

Guns and knives in New Mexico: patterns of penetrating trauma, 1978-1993

OBJECTIVE

To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.

METHODS

The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978-1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.

RESULTS

Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.

CONCLUSIONS

Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.

The aftercare of adolescents with deliberate self-harm

The evaluation and aftercare of the adolescent suicide attempter is described. The assessment of suicidal risk is aimed at the identification of those factors present in the patient and environment that make repetition of suicidal behavior likely. These factors, along with the motivation and precipitant for the suicide attempt, are used to determine the intensity of care and targets of treatment. Important elements of treatment include: obtaining a no-suicide contract, addressing potential sources of noncompliance, determining proper intensity of treatment, provision of family psychoeducation addressing ongoing family difficulties, treatment of co-occurring psychopathology, and remediation of social skills and problem-solving deficits.

Jumping the gun: firearms and the mental health of Australians

OBJECTIVES

The aims of this study were to (i) survey mental health-related correlates of firearms ownership and availability in Australia, and (ii) assess possible causal relationships between civilian gun deaths, gun availability and mental disorders.

METHOD

Available data regarding firearms ownership, injuries and deaths were reviewed as well as studies of (i) gun ownership, suicide and homicide, and (ii) gun control laws and suicide.

RESULTS

Findings indicated that 85% of firearm deaths are triggered by distress, as opposed to crime. Most firearm homicides are intrafamilial or involve familiar persons. Firearm suicide rates, although tapering off in recent years, continue to rise among certain groups. It was also found that: (1) Beyond reasonable doubt, a causal relationship exists between gun ownership and firearm suicides and homicides. The role of method substitution is controversial, but is probably less important among the young. (2) Outside the United States, legislation may be useful in reducing firearm and possibly overall suicide rates. (3) If firearm owners are representative of the community, then 15-20% suffer from a psychiatric disorder at any time. While a modest increase in risk of firearms misuse exists for this group, especially those with a history of substance abuse or violence, concern also arises regarding those with mental disorders who access firearms because owners have not secured them. No uniform definition or way of verifying self-reports exists for gun licence applicants regarding these issues.

CONCLUSIONS

Further regulation of firearm safety and availability is warranted. Public health measures include improved surveillance regarding firearm events, advocacy for appropriate firearm legislation, and better education and communication about firearms.

Violent methods associated with high suicide mortality among the young

OBJECTIVE

To present rates and trends in suicide methods, and associations between these, in male and female adolescents in the age groups 15 through 19 years and 20 through 24 years in Finland from 1947 through 1991.

METHOD

Suicide rates were calculated on the basis of the mean same-age population, and suicide trends by each method were analyzed by using the Poisson regression model. For the rates and trends, 95% confidence intervals based on the Poisson distribution were calculated.

RESULTS

The suicide rate revealed a sharp and significant increase between 1965 and 1975 for both male age groups. Firearms and hanging accounted for the majority of that increase. These figures, however, were not accompanied by similar changes in the availability of firearms during that period. Moreover, an increased total suicide rate as well as that by automobile exhaust fumes in young adults after 1982 coincided with a widely presented Finnish movie which featured this method of committing suicide. In young women, however, intake of solids and liquids remained the most common suicide method.

CONCLUSION

Suicide rates increased, especially by violent methods, which contributed to the high suicide mortality rate among the young. These methods, except firearms, however, are often difficult to restrict. This fact underlines the importance of the integration of various preventive measures of cooperation between mental health professionals and other authorities and of the recognition and care of young people at high suicide risk.

Morbidity and injury recurrence in victims of firearm injuries

Civilian violence has become an increasing problem in the industrial world. Gunshot wounds, fatal or non-fatal, are often considered as acute trauma episodes. However, our previous study, based on 820 firearm injuries, showed that this group of patients was characterized by a high mortality rate and a pronounced involvement in criminality when compared to a control group. The aim of this study was to determine the general morbidity in the same group of firearm victims. Our hypotheses were that these patients consume a considerable amount of hospital care due to recurring trauma episodes and that their general morbidity is raised. Information was collected concerning all episodes of in-patient care for victims of firearm injuries from 1972-1992 in Stockholm, Sweden. The victims were compared with a sex- and age-matched control group. During the study period, 69.9% of the 820 firearm victims were treated for other reasons than gunshot injuries, compared to 45.5% of the 820 controls. The former group was hospitalized 3,703 times and the latter on 1,512 occasions. The firearm injury group showed an higher morbidity in almost all diagnostic subgroups according to ICD-9. The trauma recurrence rate was high and suicide, homicide and assault were relatively more common in this group. We suggest that the gunshot episode may be regarded as one expression of a "chronic trauma syndrome'. Patients exhibiting this "syndrome' are characterized by recurrent episodes of trauma, a risk-taking and destructive behavior, high morbidity and mortality as well as anti-social traits. Medical, social and legal complications are common making these patients extremely costly for society and their identification a matter of concern. It is probable that this "syndrome' also exists in other groups of trauma patients. Since hospitalization affords a unique opportunity of reaching patients who have a "chronic trauma syndrome' risk profile, we believe, that these patients should not only be treated for their acute injuries, but that they should be offered help in order to change their destructive life-style. Research should be undertaken to evaluate whether an intervention program, such as counseling, could have an effect on morbidity and injury recurrence for these patients.

Sociodemographic characteristics and criminality in victims of firearm injuries

This study is based on all victims of firearm injuries (n = 820) treated in public hospitals in Stockholm, Sweden, between 1972 and 1992. The aim of the study was to determine the sociodemographic characteristics, criminality, and mortality in victims of firearm injuries. The diagnosis was accident in 56.0%, suicide/attempted suicide in 11.7%, murder/attempted murder in 20.6%, and undetermined in 11.7%. Information was procured from the Swedish National Population Register, the Swedish National Board of Health and Welfare's register on causes of death, and the Swedish National Police Board's register on sentences passed. The average victim of a firearm injury was a young man, single, and often divorced. The proportion of immigrants was larger than expected, involvement in criminality was massive, and the mortality rate was high. The risk of being killed by the gunshot if brought to the hospital alive was relatively low, except in the cases of attempted suicide. The recurrent rate in violent trauma was high. It is suggested that secondary prevention could make an important contribution to the reduction of firearm injuries and fatalities. If the necessary surgical care is supplemented with a psychosocial intervention program to help the patient change his or her current situation, the number of "chronic" victims of violence could be reduced.

Suicide in South Africa. An analysis of nationally registered mortality data for 1984-1986

Nationally registered suicide mortality data for South Africa (1984-1986) were analysed. There were 5448 deaths (1.3%) due to suicide in this period. Proportional mortality and mean annual suicide mortality rates were highest for whites, followed by Asians and then coloureds. The proportional mortality for blacks was similar to that of coloureds. Suicide was relatively prominent as a cause of death for Asian females (15-24 years). For whites, the most commonly used method of suicide was firearms. Except for coloured females, hanging was the most common method used for the other population groups. Political, economic, and religious factors may account for some of the differences. Cultural factors may explain the findings for young Asian females. There is a need for strict gun control legislation.

Suicidal ideation and attempts among chemically dependent adolescents

OBJECTIVES

Suicidal ideation and attempts were examined in a population of chemically dependent adolescents, a group at high risk of self-destructive behavior.

METHODS

The prevalence and correlates of suicidality and of major depressive disorder were assessed by the Diagnostic Interview Schedule and a structured family and social history interview with 300 addicts aged 15 through 19 years.

RESULTS

Suicidal ideation was reported by 31% to 75% of the subjects and suicide attempts were reported by 28% to 61%, with females predominating. Thoughts of suicide combined with prolonged thoughts of death in general and a desire to be dead were highly associated with suicide attempts. Exposure to physical or sexual abuse was associated with a significantly increased risk of suicide attempts for males but not for females.

CONCLUSIONS

The probability of a suicide attempt increases when thoughts of suicide coincide with morbid ideation of extended duration, suggesting that risk assessment should be based on duration as well as presence of morbid thoughts. Substance abuse treatment requires an assessment of suicidal potential and counseling for those whose potential is high, with special attention to males exposed to abuse.