Sex and age modify the relationship between life circumstances and use of a firearm in suicide deaths across 17 U.S. states

Prospective comparison of risk factors for firearm suicide and non-firearm suicide in a large population-based cohort of current and former US service members: findings from the Millennium Cohort Study

Background

Suicide is a leading cause of death among service members and veterans. Among suicide methods, firearms are the most lethal and commonly used method among military populations. Limited research has compared risk factors for the various suicide methods. This study evaluated and compared risk factors for firearm versus non-firearm suicides using data from the Millennium Cohort Study, a large longitudinal military cohort.

Methods

Using a competing risk approach, we identified factors associated with each suicide method. Risk factors included demographics, mental health diagnoses, mental health symptoms, military-specific characteristics, health behaviors, and psychosocial factors. Cause of death was assessed from July 1, 2001, through December 31, 2018.

Findings

Among 201,565 eligible participants with a mean [SD] age of 29.0 [58.1] years, there were 139,789 (69.3%) male, 61,776 (30.7%) female, 15,927 (7.9%) Hispanic, 24,667 (12.3%) non-Hispanic Black, 14,138 (7.0%) Asian, Pacific Islander, American Indian or Multiracial, and 146,736 (72.8%) non-Hispanic White participants. During the study period, 330 died by firearm suicide and 168 died by non-firearm suicide. Overall, effect estimates for risk factors were similar across both methods of suicide. After adjustment, men (HR: 3.69, 95% CI: 2.59, 5.24) and those who screened positive for depression (HR: 1.97, 95% CI: 1.36, 2.87) had an elevated risk for firearm suicide. In contrast, those who self-reported a history of bipolar diagnosis (HR: 3.40, 95% CI: 1.76, 6.55) had significantly increased risk for non-firearm suicide.

Interpretation

Findings suggest that prevention and intervention strategies overall may not need to be differentiated by specific demographic, military, or health factors. Targeted interventions that consider sex and mental health screens might have relative utility in preventing firearm related suicide risk compared with non-firearm suicide.

Funding

Military Operational Medicine Research Program, Defense Health Program, and Department of Veterans Affairs.

Firearm use risk factors and access restriction among suicide decedents age 75 and older who disclosed their suicidal intent

Background and aims

A majority of older adult suicide decedents used firearms. In this study, we focused on suicide decedents age 75+ who disclosed their suicidal intent within a month of their injury/death to examine demographic and clinical characteristics associated with firearm use and firearm access restriction attempts by their family members.

Methods

The 2017-2019 U.S. National Violent Death Reporting System provided data (N = 1,734 suicidal intent disclosers; 1,476 males and 258 females; 21.4% of decedents age 75+). Generalized linear model (GLM) for a Poisson distribution with a log link was used to examine firearm use risk factors. Firearm access restriction attempts by decedents' family members were examined based on coroner/medical examiner and law enforcement (CME/LE) reports.

Results

Nearly three quarters of disclosers disclosed their intent to family members, and 82.9% of males and 27.5% of females used firearms. GLM results showed males, non-Hispanic white people, and residents in the South and West regions had higher likelihood of firearm use. CME/LE reports of 140 out of 1,294 firearm decedents included narratives related to firearm restriction attempts or lack thereof. Firearm access restrictions were not attempted in 65 cases because family members did not take suicidal intent disclosure seriously or because decedents promised no self-harm. Partial or complete removal of firearms in 75 cases were not effective as decedents had hidden a firearm or purchased a new one. Others used different lethal methods.

Implications

The findings indicate a need for: (a) training family members of older adults who are at risk of suicide in effective means safety/access restriction and strategies to prevent means substitution; (b) more comprehensive legislative reforms reducing access to firearms by those at risk of suicide; and (c) more comfort and palliative care and counseling for psychosocial risk factors.

Preventing the most common firearm deaths: Modifiable factors related to firearm suicide

BACKGROUND

More than 20,000 firearm suicides occur every year in America. Firearm restrictive legislation, firearm access, demographics, behavior, access to care, and socioeconomic metrics have been correlated to firearm suicide rates. Research to date has largely evaluated these contributors singularly. We aimed to evaluate them together as they exist in society. We hypothesized that state firearm laws would be associated with reduced firearm suicide rates.

METHODS

We acquired the 2013 to 2016 data for firearm suicide rates from The Centers for Disease Control Wide-ranging Online Data for Epidemiologic Research. Firearm laws were obtained from the State Firearms Law Database. Depression rates and access to care were obtained from the Behavioral Risk Factor Surveillance System and Occupational Employment and Wage Statistics program. Population demographics, poverty, and access to social support were obtained from the American Community Survey. Firearm access estimates were retrieved from the National Instant Criminal Background Check System. We used a univariate panel linear regression with fixed effect for state and firearm suicide rates as the outcome. We created a final multivariable model to determine the adjusted associations of these factors with firearm suicide rates.

RESULTS

In univariate analysis, firearm access, heavy drinking behavior, demographics, and access to care correlated to increased firearm suicide rates. The state proportion identifying as white and the proportion of those in poverty receiving food benefits correlated to decreased firearm suicide rates. In multivariable regression, only heavy drinking (β, 0.290; 95% confidence interval, 0.092-0.481; P = .004) correlated to firearm suicides rates increases.

CONCLUSIONS

During our study, few firearm laws changed. Heavy drinking behavior association with firearm suicide rates suggests an opportunity for interventions exists in the health care setting.

Injury characteristics and circumstances of firearm trauma: Assessing suicide survivors and decedents

INTRODUCTION

Despite representing fewer than 5% of suicide attempts, firearms account for over half of deaths. Yet there is little clinical information regarding firearm attempts, particularly survivors. We assessed clinical factors differentiating firearm suicide survivors from decedents, firearm attempters from other methods, and firearm attempters from similarly injured trauma patients.

METHODS

We used clinical data from the National Trauma Data Bank (2017) to assess firearm suicide attempts using cross-sectional and case-control designs. We used logistic and multinomial regression to compare groups and assess firearm type and discharge destination.

RESULTS

Older age, being uninsured, and injury location were associated with increased mortality among firearm attempters. Older age, White race, male sex, and being uninsured were associated with firearm attempts. Major psychiatric disorders were associated with firearm attempts and using a rifle or shotgun. Major psychiatric disorders, female sex, and smoking were associated with psychiatric discharge. Black and other race were associated with law enforcement discharge, and Black race was associated with lower odds of psychiatric discharge. Uninsured patients had lower odds of discharge to long-term care, psychiatric, or rehabilitation facilities.

CONCLUSIONS

This study identifies factors associated with firearm suicide and includes indicators of disparities in health services for patients at high risk of suicide death.

Exploring Contextual Factors Associated with Suicide among Older Male Farmers: Results from the CDC NVDRS Dataset

Objectives: The purpose of this study was to explore how demographic, relationship, mental health, and life stressors are associated with suicide among older male farmers and to determine if these differ by age.Methods: We conducted exploratory analyses with Centers for Disease Control (CDC) National Violent Death Reporting System (NVDRS) 2003-2017 dataset. We identified individuals who completed suicide while working in agriculture (N = 2,106). We explored descriptive statistics for farmers who completed suicide and compared these by age using chi-square tests.Results: The majority of the sample was male, non-Hispanic, and White. Marital status differed significantly by age, with older farmers more likely to be married or widowed. Having a mental health issue was not statistically significant by age; however, depression was most prevalent among those 65+. Older farmers who completed suicide were also significantly more likely to report physical health problems.Conclusions: Results illustrate the vulnerability of individuals contemplating suicide and emphasize the need to consider the phenomenon from a holistic perspective that accounts for individuals nested within community.Clinical implications: We recommend health providers consider a systems approach to suicide prevention as our results indicate individual, familial, and societal factors contributing to the incidence of suicide completion among older farmers.

Association of mental disorders with firearm suicides: A systematic review with meta-analyses of observational studies in the United States

In the United States (US), 61% of all suicide cases may involve firearms, and some evidence suggests that mental disorders may play a role in suicide by firearm. We performed the first systematic review and meta-analyses to investigate: (i) whether mental disorders are associated with suicide by firearm, and (ii) whether the risk of using a firearm compared with alternative means is associated with higher levels of suicide in individuals with a mental disorder METHODS AND FINDINGS: We searched twelve databases from inception to the 24th of May 2020. We retrieved 22 observational studies conducted in the US. Random-effects meta-analyses showed individuals who had a diagnosis of a mental disorder had lower odds (odds ratios (OR)= 0.50, 95% CI: 0.36 to 0.69; I²=100 (95% CI: 87 to 100%), of dying by suicide with a firearm than those who did not have a diagnosis of a mental disorder. Secondary analysis showed that decedents who had a mental health diagnosis resulted in lower odds of dying by suicide by using firearms than using other means LIMITATIONS: Risk of bias revealed a heterogeneous and poor definition of mental disorders as well as lack of control for potential demographic confounding factors. In the meta-analyses, studies were combined in the same analytic sample as 77% of these studies did not specify the type of mental disorder CONCLUSION: While our results seem to suggest that having a mental disorder may not be consistently associated with the odds of dying by suicide using a firearm, the presence of substantial heterogeneity and high risk of bias precludes any firm conclusions.

The Collision of Mental Health, Substance Use Disorder, and Suicide

Suicide is the 10th leading cause of death, and, in women, nearly half of all suicide deaths occur during their reproductive years. Suicide is associated with psychiatric illness, especially mood and anxiety disorders. Childhood adversities, such as physical, emotional, and sexual abuse, and intimate partner violence increase the risk of suicide. Having more than one psychiatric disorder or comorbid substance use disorder also increases the risk of suicide. Substance use disorders can be the triggering factor for a suicide attempt among those who have a psychiatric condition and suicidal thoughts. Women attempt suicide three times more often than men, although they are less likely to complete suicide. Although the rate of suicide decreases in the perinatal period, pregnant women are more likely to use violent means. Women who complete suicide in the perinatal period are also more likely to be younger, married, and experiencing a depressive episode. For many women, the only encounter with the medical system they have might be in reproductive health care clinics. This means that their obstetrician-gynecologist has a unique opportunity to address women's mental health and enhance suicide prevention. The American College of Obstetricians and Gynecologists recommends screening for depression among perinatal women. Clinicians need to be aware that women with severe perinatal depression are at increased risk of suicide and that women with suicidal thoughts need careful monitoring, evaluation, and treatment.

Patterns and Trends of Gun Violence Against Women in the United States

OBJECTIVE

To examine patterns and trends of firearm injuries in a nationally representative sample of US women.

SUMMARY OF BACKGROUND DATA

Gun violence in the United States exceeds rates seen in most other industrialized countries. Due to the paucity of data little is known regarding demographics and temporal variations in firearm injuries among women.

METHODS

Data were extracted from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System (2001-2017) for women 18 years and older. Number of nonfatal firearm assaults and homicide per year were extracted and crude population-based injury rates were calculated. Sub-stratification by age-group and time period were performed.

RESULTS

Between 2001 and 2017, there were 88,823 nonfatal firearm assaults involving women and 29,106 firearm homicides. There were 4116 victims of nonfatal firearm assault in 2001 (3.8 per 105) and 12,959 by 2017 (10.0 per 105). Homicide rates were 1.5 per 105 in 2001 and 1.7 per 105 in 2017. Sub-stratification by age-group and time period showed that there were no significant changes in nonfatal firearm assault rates between 2001 and 2010 (P-trend = 0.132 in 18-44 yo; 0.298 in 45-64 yo). However between 2011 and 2017, nonfatal assault rates increased from 7.10 per 105 to 19.24 per 105 in 18-44 yo (P-trend = 0.013) and from 1.48 per 105 to 3.93 per 105 in 45-64 yo (P-trend = 0.003). Similar trends were seen with firearm homicide among 18-44 yo (1.91 per 105 to 2.47 per 105 in 2011-2017, P-trend = 0.022). However, the trends among 45-64 yo were not significant in both time periods.

CONCLUSIONS

Female victims of gun violence are increasing and more recent years have been marked with higher rates of firearm injuries, particularly among younger women. These data suggest that improved public health strategies and policies may be beneficial in reducing gun violence against US women.

Clinical diagnostic phenotypes in hospitalizations due to self-inflicted firearm injury

BACKGROUND

. Hospitalized self-inflicted firearm injuries have not been extensively studied, particularly regarding clinical diagnoses at the index admission. The objective of this study was to discover the diagnostic phenotypes (DPs) or clusters of hospitalized self-inflicted firearm injuries.

METHODS

. Using Nationwide Inpatient Sample data in the US from 1993 to 2014, we used International Classification of Diseases, Ninth Revision codes to identify self-inflicted firearm injuries among those ≥18 years of age. The 25 most frequent diagnostic codes were used to compute a dissimilarity matrix and the optimal number of clusters. We used hierarchical clustering to identify the main DPs.

RESULTS

. The overall cohort included 14072 hospitalizations, with self-inflicted firearm injuries occurring mainly in those between 16 to 45 years of age, black, with co-occurring tobacco and alcohol use, and mental illness. Out of the three identified DPs, DP1 was the largest (n=10,110), and included most common diagnoses similar to overall cohort, including major depressive disorders (27.7%), hypertension (16.8%), acute post hemorrhagic anemia (16.7%), tobacco (15.7%) and alcohol use (12.6%). DP2 (n=3,725) was not characterized by any of the top 25 ICD-9 diagnoses codes, and included children and peripartum women. DP3, the smallest phenotype (n=237), had high prevalence of depression similar to DP1, and defined by fewer fatal injuries of chest and abdomen.

LIMITATIONS

. Claims data.

CONCLUSIONS

. There were three distinct diagnostic phenotypes in hospitalizations due to self-inflicted firearm injuries. Further research is needed to determine how DPs can be used to tailor clinical care and prevention efforts.

The Association between Firearm Control Policies and Firearm Suicide among Men: A State-Level Age-Stratified Analysis

This study examined the association between state-specific firearm control policies and firearm suicide rates among men after adjusting for state-level demographics. This cross-sectional study used state-level mortality data from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System and the Brady Campaign State Scorecard in 2017. An age-stratified (15-24 years, 25-44 years, 45-64 years, and ≥ 65 years) multivariable analysis was conducted to identify gun control policies that are associated with firearm suicide rates among men in each age group. Results indicate that the associations of specific firearm control policies and firearm suicide rates differ across the age span. In particular, more policies (for example, dealer regulations and waiting periods) are negatively associated with firearm suicide rate among men 15 to 24 years of age. The findings underscore the importance of designing gender- and age-specific policy advocacy programs directed at lowering the rate of firearm suicide. This study also suggests that California, known for its innovative gun safety legislation efforts, could serve as a model for other states starting preventive programs to reduce the firearm suicide rate. Implications of the findings for social work practice are discussed.

Examining the Association between Weapon Carrying on School Property and Suicide Attempt among Adolescents in the United States

Suicidal behaviors among adolescents in the United States are the second leading cause of death and has been steadily increasing over the years. Although access to and possession of a weapon may facilitate the transition from suicidal ideation to a suicide attempt, few studies have examined the association between weapon carrying and suicide attempts among adolescents. The objective of this study was to examine the association between weapon carrying on school property and suicide attempt among adolescents. Data for this study came from the 2017 Youth Risk Behavior Surveillance System. A sample of 14,547 adolescents aged 14-18 years old (50.5% female) was analyzed using logistic regression. Of the 14,547 adolescents, 4% carried a weapon on school property, and 7.7% attempted suicide during the past 12 months. In the multivariate logistic regression, adolescents who reported carrying a weapon on school property had more than double the odds of attempting suicide when compared to their counterparts who did not carry a weapon on school property. Other significant predictors of suicide attempt include sexual minority, history of forced sexual intercourse, school bullying and cyberbullying victimization, feeling sad or hopeless, and substance use. Examining the association between weapon carrying and suicide attempt among adolescents would contribute to early identification of adolescents who are likely to engage in suicidal behaviors.

What's Unique About Lesbian, Gay, Bisexual, and Transgender (LGBT) Youth and Young Adult Suicides? Findings From the National Violent Death Reporting System

PURPOSE

The purpose of the study was to explore variability in circumstances around suicide deaths among youth and young adults by sexual/gender identity category (gay male, lesbian/gay female, bisexual male, bisexual female, transgender male, transgender female, non-LGBT [lesbian, gay, bisexual, and transgender] male, and non-LGBT female).

METHODS

Secondary analysis of National Violent Death Reporting System (NVDRS) data for all 12- to 29-year-olds who died by suicide in NVDRS participating states. Coverage begins in 2013, the year that NVDRS began coding for sexual orientation and transgender status, and ends in 2015, the latest year of NVDRS data available. The valid sample was limited to cases in which sexual orientation or transgender status could be determined postmortem, n = 2,209.

RESULTS

Almost one quarter (24%) of 12- to 14-year-olds who died by suicide were LGBT, whereas only 8% of 25- to 29-year-olds who died by suicide were LGBT. Most non-LGBT males and bisexual males died by firearm and had intimate partner problems contribute to their deaths. Non-LGBT females and LGBT persons other than bisexual males were generally less likely to use firearms. They were also more likely to have psychiatric diagnoses, prior suicidality, and family problems contributing to their deaths. Rates of many circumstances varied widely among LGBT subgroups.

CONCLUSIONS

The LGBT versus non-LGBT suicide disparity is greatest at younger ages, and each LGBT subgroup has its own specific risk profile for suicide. Suicide prevention and intervention efforts targeted at LGBT youth may increase their effectiveness by attending to these distinct risk profiles.

Limiting access to lethal means: applying the social ecological model for firearm suicide prevention

This paper outlines a novel application of the social ecological model (SEM) for firearm suicide prevention. It focuses on four levels of intervention (societal, relationship, community and individual) to reduce access to firearms, a practical contributor to the capacity to attempt suicide, from individuals when they are at an elevated risk for suicide. There is substantive research linking easy access to firearms with an increased risk of firearm suicide, and suicide prevention interventions that address access to lethal means are critical components of a comprehensive suicide prevention strategy. Potential interventions using the SEM framework include: at the policy level-extreme risk laws, voluntary self-prohibition policies and policies that reduce the availability of firearms; at the community level-gun shop projects; at the relationship level-lethal means safety counselling; and at the individual level-safer storage. Taken together with upstream interventions, such as increased access to mental health services and substance use treatment, a multilevel approach for suicide prevention that addresses access to firearms can save lives.