Firearms and suicide

Threat perceptions, defensive behaviors, and the perceived suicide prevention value of specific firearm storage practices

INTRODUCTION

Secure firearm storage has been proposed as a suicide prevention method within the military; however, secure storage practices are uncommon. Service members may perceive limited value in secure storage as a suicide prevention tool and threat-related factors may influence such perceptions.

METHOD

A nationally representative sample of firearm-owning military service members (n = 719) was recruited between December 3, 2021 and January 4, 2022 to complete a self-report survey by Ipsos using their KnowledgePanel calibration approach to optimize representativeness.

RESULTS

Threat sensitivity was associated with less perceived suicide prevention value across all within-home storage practices as well as out-of-home storage. Defensive firearm ownership was associated with less perceived out-of-home storage value. Contrary to expectations, PTSD symptoms were associated with greater perceived suicide prevention value across all storage practices and intolerance of uncertainty was associated with greater perceived out-of-home storage value.

DISCUSSION

Perceptions of, sensitivity to, and reactions to threat represent a complicated confluence of factors that may influence firearm views and behaviors in disparate ways. Viewing the world as dangerous and other people as a threat may limit perceived suicide prevention value for secure storage and increase the drive for firearm access.

Reducing firearm access for youth at risk for suicide in a pediatric emergency department

Background

Firearm-related suicide is the second leading cause of pediatric firearm death. Lethal means counseling (LMC) can improve firearm safe-storage practices for families with youth at risk of suicide.

Objectives

This study aims to evaluate the feasibility of pediatric emergency department (ED) behavioral mental health (BMH) specialists providing LMC to caregivers of youth presenting with BMH complaints and to test for changes in firearm safety practices, pre-post ED LMC intervention, as measures of preliminary efficacy.

Methods

Prospective pilot feasibility study of caregivers of youth presenting to a pediatric ED with BMH complaints. Caregivers completed an electronic survey regarding demographics and firearm safe-storage knowledge/practices followed by BMH specialist LMC. Firearm owners were offered a free lockbox and/or trigger lock. One-week follow-up surveys gathered self-reported data on firearm safety practices and intervention acceptability. One-month interviews with randomly sampled firearm owners collected additional firearm safety data. Primary outcomes were feasibility measures, including participant accrual/attrition and LMC intervention acceptability. Secondary outcomes included self-reported firearm safety practice changes. Feasibility benchmarks were manually tabulated, and Likert-scale acceptability responses were dichotomized to strongly agree/agree vs. neutral/disagree/strongly disagree. Descriptive statistics were used for univariate and paired data responses.

Results

In total, 81 caregivers were approached; of which, 50 (81%) caregivers enrolled. A total of 44% reported having a firearm at home, 80% completed follow-up at one week. More than 80% affirmed that ED firearm safety education was useful and that the ED is an appropriate place for firearm safety discussions. In total, 58% of participants reported not having prior firearm safety education/counseling. Among firearm owners (n = 22), 18% reported rarely/never previously using a safe-storage device, and 59% of firearm owners requested safe storage devices.At 1-week follow-up (n = 40), a greater proportion of caregivers self-reported asking about firearms before their child visited other homes (+28%). Among firearm owners that completed follow-up (n = 19), 100% reported storing all firearms locked at one week (+23% post-intervention). In total, 10 caregivers reported temporarily/permanently removing firearms from the home.

Conclusion

It is feasible to provide LMC in the pediatric ED via BMH specialists to families of high-risk youth. Caregivers were receptive to LMC and reported finding this intervention useful, acceptable, and appropriate. Additionally, LMC and device distribution led to reported changes in safe storage practices.

Impact of handgun ownership and biological sex on startle reactivity to predictable and unpredictable threats

Extant literature suggests that many individuals obtain firearms because they perceive the world as unsafe and believe that firearm ownership increases physical protection. Converging evidence suggests that firearm owners are vulnerable to uncertainty and experience chronic anticipatory anxiety in daily life; however, biological sex is thought to potentially moderate this association. Studies have yet to examine this hypothesis using objective markers of anticipatory anxiety. The present study therefore examined the impact of handgun ownership and biological sex on psychophysiological reactivity to predictable (P-) and unpredictable (U-) threat (N = 133). Male and female adult participants were classified into two groups: a) individuals who do not currently own any handguns (n = 52), and b) individuals who currently own one or more handguns (n = 81). Startle eyeblink potentiation was recorded as an index of aversive reactivity during a well-validated threat-of-shock paradigm designed to probe anticipatory anxiety (during U-threat) and fear (during P-threat). Results revealed no main effect of group on startle reactivity to P- or U-threat. Females displayed greater startle reactivity to threat (P- and U-) compared with males. The main effect was qualified by a significant group x biological sex interaction. Male handgun owners exhibited greater startle to U-threat, but not P-threat, relative to non-handgun owners. There was no effect of group on startle reactivity in females. Findings revealed that biological sex and threat type influenced threat reactivity. Male handgun owners displayed increased sensitivity to stressors that are uncertain, which may reflect an objective mechanism related to firearm ownership.

Conformity to masculine role norms, firearm storage behaviors, and openness to means safety among two samples of firearm owners

OBJECTIVE

Understanding the sociocultural characteristics that are associated with US firearm owners' current storage practices and openness to means safety can inform suicide prevention initiatives. Masculinity, which is dominant within the US gun culture, may be a particularly salient factor that influences firearm ownership, storage practices, and openness to means safety. A recent study by McDermott et al. (2021) found that firearm ownership was associated with a combination of being White, male, politically conservative, and endorsing higher conformity to the masculine norms of violence, risk taking, and power over women. The current study builds upon McDermott and colleagues' (2021) research by examining the unique contribution of conformity to nine masculine norms as predictors of current firearm storage practices and openness to firearms means safety.

METHODS

Two samples of US firearm owners were recruited on Amazon's Mechanical Turk in 2019 (Sample 1; n = 200) and 2020 (Sample 2; n = 297).

RESULTS

Higher adherence to the norms of emotional control, violence, and power over women were associated with less secure storage practices, but only in Sample 2. The hypothesis that self-reliance, emotional control, and risk taking would be associated with openness to means safety was largely unsupported. Adherence to the violence norm was observed to have the greatest association with both current storage practices and openness to changing storage practices.

CONCLUSIONS

While several masculine norms were not consistently associated with our outcomes, the norm of violence may play a small role in firearm storage practices and openness to means safety for suicide prevention.

Handgun Divestment and Risk of Suicide

BACKGROUND

Firearm ownership is strongly related to suicide risk, yet little is known about how much risk declines when ownership ends ("divestment").

METHODS

Using data from 523,182 handgun owners, we estimated the effect of divesting and remaining divested versus never divesting on the risk of suicide and firearm-specific suicide. We used pooled logistic regression with inverse probability weighting, adjusting for demographic and area-level measures.

RESULTS

The 5-year risk of suicide death was 25.6 (95% confidence interval [CI] = 15.1, 37.2) per 10,000 persons with divestment and 15.2 (95% CI = 13.2, 17.3) per 10,000 persons with no divestment, corresponding to a risk difference of 10.4 (95% CI = 0.7, 21.1) per 10,000 persons. The 5-year risk of firearm-specific suicide death was 6.3 (95% CI = 1.4, 11.9) per 10,000 persons with divestment and 12.9 (95% CI = 11.0, 14.6) per 10,000 persons with no divestment, corresponding to a risk difference of -6.6 (95% CI = -11.4, -0.1) per 10,000 persons. Comparing divestment to no divestment, risks were elevated for deaths due to other causes proposed as negative control outcomes; we incorporated these estimates into a series of bias derivations to better understand the magnitude of unmeasured confounding.

CONCLUSIONS

Collectively, these estimates suggest that divestment reduces firearm suicide risk by 50% or more and likely reduces overall suicide risk as well, although future data collection is needed to fully understand the extent of biases such as unmeasured confounding.

Identifying Points of Prevention in Firearm-Related Suicides: A Mixed-Methods Study Based on Coronial Records

PURPOSE

Firearm-related suicide is a noteworthy and preventable public health issue that has drawn limited attention in Australian research. Firearms are highly lethal and remain in the top three methods of suicide among Australian males. This study examines suicides occurring in Tasmania, the jurisdiction with the highest rate of firearm-related suicide, with the aim of aiding suicide prevention strategies.

METHODS

A mixed-methods approach was used to analyze data from the Tasmanian Suicide Register. The quantitative analysis examined socio-demographic factors, substance use, physical and mental health, and access to services for suicides occurring between January 1, 2012 and December 31, 2016. The qualitative analysis comprised firearm-related suicides occurring between January 1, 2012 and December 31, 2017.

RESULTS

Firearms users were more likely than those employing other means of suicide to be male, retired, and residing in remote areas but were less likely to have had a previous mental illness diagnosis or evidence of suicidal ideation or self-harming behaviors. There was some evidence of increased impulsiveness among firearm users. We found 54% of decedents were licensed to own a firearm at the time of death. Firearms most often belonged to the decedent (52%) and 26% sourced a firearm from family or friends. Only 58% of cases involved a firearm with a dedicated storage facility.

CONCLUSIONS

Prevention efforts need to take into account the unique profiles of those at risk of firearm-related suicide. Impulsiveness and the varying levels of adherence to firearms safety practices point to the need for strategies that limit physical access to firearms.HIGHLIGHTSFirearms-related suicides have a unique risk profile compared with other means of suicide.Mental illness diagnosis, suicidal thoughts, and self-harming behaviors were less commonly identified among firearms-related suicides than other means of suicide.Impulsiveness and the varying levels of adherence to firearms safety practices point to the need for strategies that limit physical access to firearms.

Determining subgroups that exist among US firearm owners

OBJECTIVE

To identify and verify classes of firearm owners that exist within the United States and determine the sources that classes deemed credible to discuss firearm safety for suicide prevention.

METHODS

The study is composed of two parts. Part 1 (N = 1018) utilizes a nationally representative sample of firearm owners. Part 2 (N = 1064) consists of firearm owners from Mississippi, Minnesota, and New Jersey.

RESULTS

Four unique classes were identified in Sample 1: multiple firearms class, single handgun class, few firearms class, and long-gun class. A three-class solution was found for sample 2. Two of the classes from sample 1 replicated: multiple firearms class and single handgun class. Although many of the classes differed in the ranking of credible sources, a combination of The American Foundation for Suicide Prevention, law enforcement officers, and family members was ranked as credible sources among all classes.

CONCLUSIONS

Findings provide evidence of the heterogenous nature of firearm owners and can be utilized to better understand the subgroups of firearm owners. Additionally, the findings from the credible sources analyses can be leveraged to create more effective safe firearm storage messaging which may increase adherence with safe storage suggestions and ultimately reduce suicide rates.

Home as the first site for suicide prevention: a Hong Kong experience

INTRODUCTION

There has been little research into at-home suicide cases globally, and particularly in Asian regions. This study aimed to investigate the differences in characteristics between suicide cases in Hong Kong that occurred at home and elsewhere; identify at-home suicide hotspots in the community and compare the differences in area-level characteristics between suicide hotspots and other areas.

METHODS

Suicide cases (2013-2017) were identified from Hong Kong Coroner's Court reports. Area-level socioeconomic data were retrieved from the 2016 Hong Kong census. Wilcoxon signed-rank tests, χ² tests and multiple logistic regression models were applied to compare differences in characteristics between people committing suicide at home and elsewhere. Global hotspot tests (Moran's I and Getis-Ord General G) and local analysis (Getis-Ord Gi*) identified at-home suicide community hotspots. The Wilcoxon signed-rank test was used to compare differences in area-level characteristics between at-home suicide hotspots and non-hotspots.

RESULTS

About 60% of suicide cases in Hong Kong occurred at home. Being female, widowed and/or living alone were significant predictors of at-home suicide cases. A U-shaped association between age and at-home suicide was identified, with 32 years of age being the critical turning point. An at-home suicide hotspot was identified in the north-western region of Hong Kong, which had lower median household income, higher income inequality and higher percentages of households with single elderly people, and new arrivals, compared with other areas.

CONCLUSION

Suicide prevention should start at home by restricting access to suicide methods. Community-based suicide prevention interventions with improvement of social services should target vulnerable members in identified suicide hotspots.

A high-need, high-impact educational session on firearms and death by suicide

BACKGROUND

The suicide rate among Veterans is 1.5 times greater than that for civilians, partly a result of the high use of firearms as the means for suicide. One effective strategy to reduce Veteran suicide by firearms is to provide counseling on firearm safety as a method of means reduction. However, many clinicians do not discuss firearm safety with Veterans.

AIMS

This study evaluates a one-hour educational seminar for clinicians on lethal means safety.

MATERIALS AND METHODS

One hundred and ninety clinicians from the Veterans Health Administration, including social workers, psychologists, psychiatrists, and nurses, participated in the training. The seminar was streamed during the South Central Mental Health Illness Research, Education and Clinical Center's Community-Based Outpatient Clinic Mental Health Grand Rounds, for which participants were eligible for continuing education units. Data were collected immediately after the training and four months later.

RESULTS

After completing the training, participants believed that it was important to speak with Veterans about firearm safety and felt knowledgeable and empowered to do so. Four months after the seminar, participants had counseled, on average, over half of Veterans treated about lethal means safety.

DISCUSSION

Participants reported the value of normalizing discussions about firearm safety with their Veterans and focusing on the safety aspect while discussing firearms.

CONCLUSIONS

This webinar was effective in providing clinicians the skills to talk with Veterans about firearm safety and continued to impact their practice four months after training. The training is available for free on our website at https://www.mirecc.va.gov/visn16/public-health-approach-to-firearms-and-death-by-suicide.asp.

The Airman's Edge Project: A Peer-Based, Injury Prevention Approach to Preventing Military Suicide

In light of data indicating military personnel are more likely to reach out to peers during times of need, peer-to-peer (P2P) support programs have been implemented for military suicide prevention. Often designed to reduce suicidal thoughts and behaviors by reducing mental health symptom severity, existing data suggest that P2P programs have little to no effect on mental health symptoms. Conceptualizing suicide prevention from an occupational safety and injury prevention perspective to promote positive health-related behavior change at both the group and individual level may enhance the effectiveness of P2P programs and military suicide prevention efforts more broadly. To illustrate these concepts, the present article provides an overview of the Airman’s Edge project, a P2P program design based upon the occupational safety and injury prevention model of suicide prevention, and describes a program evaluation effort designed to test the effectiveness of this approach.

Lethal Means Counseling, Distribution of Cable Locks, and Safe Firearm Storage Practices Among the Mississippi National Guard: A Factorial Randomized Controlled Trial, 2018-2020

Objectives. To examine whether lethal means counseling and provision of cable locks prompt safe firearm storage relative to control among firearm-owning members of the Mississippi National Guard.Methods. This randomized controlled trial utilized a 2 × 2 factorial design (lethal means counseling vs control, provision of cable locks vs no cable locks). Follow-up assessments took place at 3 and 6 months after baseline. Data were collected (n = 232; 87.5% male; mean age = 35.01 years; 77.2% White) from February 2018 through July 2020.Results. Relative to control, lethal means counseling and provision of cable locks resulted in greater adoption of several safe storage methods over time. Lethal means counseling outperformed control (3 months: 55.0% vs 39.0%; odds ratio [OR] = 1.91). Cable locks outperformed control at 3 and 6 months on number of storage methods (1.41 vs 1.11; d = 0.29 and 1.34 vs 1.16; d = 0.15, respectively) and locking devices (59.8% vs 29.9%; OR = 3.49 and 58.4% vs 35.8%; OR = 2.52, respectively)Conclusions. Lethal means counseling and cable locks can result in sustained changes in firearm storage.Public Health Implications. The military may benefit from lethal means counseling, perhaps administering at point of entry.Trial Registration. Clinical Trials.gov identifier: NCT03375099.

Threat perceptions and the intention to acquire firearms

Firearm sales have surged during COVID-19, raising concerns about a coming wave of suicide deaths. Little is known, however, about the individuals considering acquiring firearms during the pandemic. Recent research has highlighted that individuals considering acquiring firearms may be motivated by exaggerated threat expectancies. In a sample of 3,500 Americans matched to 2010 United States Census data, we compared individuals intending to buy firearms in the coming 12 months (assessed in late June and early July 2020) to those undecided or not planning to acquire firearms on a range of demographic, anxiety, and firearm ownership variables. Our results indicated that those intending to acquire a firearm in the next twelve months are less tolerant of uncertainty, endorse exaggerated threat expectancies, and are experiencing more severe COVID-19 specific fears. Individuals intending to purchase firearms were also more likely to have experienced suicidal ideation in the past year, to have worked in law enforcement, and to have been considered essential workers during COVID-19. Furthermore, such individuals were more likely to already own firearms and to have purchased firearms during the opening months of the COVID-19 pandemic. Those intending to purchase firearms did not endorse lower perceived neighborhood safety, however, indicating that their intent to purchase firearms is unlikely to be driven by tangible threats in their immediate environment. These findings highlight that exaggerated fears may be motivating individuals to purchase firearms to diminish anxiety and that this trend may be particularly common among individuals who already own firearms.

Sexual and Gender Minority Status and Firearms in the Household: Findings From the 2017 Behavioral Risk Factor Surveillance System Surveys, California and Texas

OBJECTIVES

Although lesbian, gay, bisexual, and transgender (LGBT) people have a higher prevalence of reporting a lifetime suicide attempt than non-LGBT people, suicide prevention research on access to lethal means (eg, firearms) among LGBT people is limited. Our study examined (1) the presence of firearms in the home and (2) among respondents with firearms in the home, the storage of firearms as stored unloaded, stored as loaded and locked, or stored as loaded and unlocked.

METHODS

We used data from the 2017 Behavioral Risk Factor Surveillance System surveys from California and Texas (N = 11 694), which were the only states to include items about both sexual orientation and gender identity and the status of firearms in the home. We used logistic regression analysis to assess the association of sexual orientation and gender identity with having firearms in the home while accounting for sociodemographic characteristics and survey state. All analyses were weighted to account for the complex sampling design.

RESULTS

Approximately 4.2% of the sample identified as lesbian, gay, and bisexual (LGB). About 18.2% of LGB people reported firearms in the home compared with 29.9% of their heterosexual peers. After adjusting for sex, age, race/ethnicity, educational attainment, and military veteran status, LGB respondents had significantly lower odds of reporting firearms in the home than their heterosexual peers (adjusted odds ratio = 0.47; 95% CI, 0.27-0.84). Among respondents with firearms in the home, firearm storage did not differ by sexual orientation.

CONCLUSIONS

Further research is needed to examine whether lower odds of firearms in the home are protective against suicide deaths among LGB populations.

Veterans, Firearms, and Suicide: Safe Storage Prevention Policy and the PREVENTS Roadmap

BACKGROUND

US veterans die by suicide at a higher rate than that of the civilian population and are more likely to use a firearm as their method. Systemic efforts to address the use of firearms in suicide had been largely evaded. In June 2020, the White House published the Roadmap to Empower Veterans and End the National Tragedy of Suicide (PREVENTS) task force report, which verified the link between, and the need to address, at-risk veterans and their access to firearms. This paper reviews the literature on the intersection of veterans, firearms, and suicide, then explores existing VA prevention initiatives aimed at reducing at-risk veterans' access to lethal means and offers policy recommendations to expand efforts in the context of the PREVENTS Roadmap.

OBSERVATIONS

The PREVENTS report recommends widespread distribution of safety education materials that encourage at-risk individuals to temporarily transfer or store their guns safely and the expansion of free or affordable options for storing weapons. Recommended policy actions to accomplish this goal include delaying access to firearms for at-risk veterans, facilitating temporary storage out of the home, improving in-home safe storage options, requiring that health care providers who care for high-risk veterans are trained in lethal means safety counseling, and creating campaigns to shift cultural norms for firearms' storage during crises.

CONCLUSIONS

Suicide prevention requires a multimodal approach, and attention to firearms access must become a more salient component. The high rate of veteran suicides involving firearms requires far-reaching interventions at societal, institutional, community, family, and individual levels.

Firearm access and adolescent suicide risk: toward a clearer understanding of effect size

BACKGROUND

Strong and consistent associations between access to firearms and suicide have been found in ecologic and individual-level observational studies. For adolescents, a seminal case-control study estimated that living in a home with (vs without) a firearm was associated with a fourfold increase in the risk of death by suicide.

METHODS

We use data from a nationally representative study of 10 123 US adolescents aged 13-18 years to (1) measure how much adolescents who live in a home with a firearm differ from those who do not in ways related to their risk of suicide, and (2) incorporate these differences into an updated effect estimate of the risk of adolescent suicide attributable to living in a home with firearms.

RESULTS

Almost one-third (30.7%) of adolescents reported living in a home with firearms. Relative to those who did not, adolescents reporting living in a home with a firearm were slightly more likely to be male, older and reside in the South and rural areas, but few differences were identified for mental health characteristics. The effect size found by Brent and colleagues appeared robust to sources of possible residual confounding: updated relative risks remained above 4.0 across most sensitivity analyses and at least 3.1 in even the most conservative estimates.

CONCLUSIONS

Although unmeasured confounding and other biases may nonetheless remain, our updated estimates reinforce the suggestion that adolescents' risk of suicide was increased threefold to fourfold if they had lived in homes with a firearm compared with if they had not.

Changes in Firearm and Medication Storage Practices in Homes of Youths at Risk for Suicide: Results of the SAFETY Study, a Clustered, Emergency Department-Based, Multisite, Stepped-Wedge Trial

STUDY OBJECTIVE

We evaluate whether a counseling intervention implemented at the hospital level resulted in safer firearm and medication storage by caregivers of youths aged 10 to 17 years after their child's evaluation in the emergency department (ED) for a behavioral health concern.

METHODS

We used a stepped-wedge clustered design rolled out at 4 hospital sites to assess primary preregistered outcomes (self-reported storage changes caregivers made to household firearms and medications), assessed by survey 2 weeks after the ED visit. Three logistic models provided estimates of the intervention effect: an unadjusted model, a model with hospital-level fixed effects, and a model that further adjusts for time.

RESULTS

Of the 575 caregiver participants, 208 were firearm owners (123 in usual care, 85 in the intervention). Baseline (pre-ED visit) characteristics did not differ between usual care and intervention phases. During the 2-year study period, twice as many caregivers whose child visited the ED after (compared with before) a hospital adopted the intervention improved firearm storage and 3 times as many improved medication storage (odds ratio [OR]=2.1 [95% confidence interval {CI} 1.0 to ∞] and OR=3.0 [95% CI 2.2 to ∞], respectively). After adjusting for time, the intervention effect for medications persisted (OR=2.0 [95% CI 1.0 to ∞]); the effect on firearms did not (OR=0.7 [95% CI 0.1 to ∞]).

CONCLUSION

To our knowledge, this study is the first controlled trial to estimate the effectiveness of an intervention on firearm and medication storage in homes of youths at elevated risk of suicide. We found evidence that caregivers' medication storage improved after their child's ED visit, with evidence suggestive of improvement for firearm storage.

Possession of Household Firearms and Firearm-Related Discussions with Clinicians Among Veterans Receiving VA Mental Health Care

Objectives: To assess possession of household firearms among veterans receiving mental health care and the frequency of their discussions with clinicians about firearms. Methods: We surveyed random samples of veterans receiving mental health care in each of five purposively chosen, geographically diverse VA facilities; 677 (50% of recipients) responded. Results: 45.3% (95% CI 41.2, 49.3) of veteran respondents reported household firearms; 46.9% of those with suicidal thoughts and 55.6% with a suicide plan had household firearms. Only 27.5% of all veteran respondents and 44% of those with recent suicidal ideation and household firearms had had a firearm-related discussion with a clinician. Discussion: Many veterans receiving mental health care can readily access firearms, a highly lethal means for suicide. Increasing clinician-patient discussions and health system efforts to reduce firearm access might reduce suicide in this clinical population.

Type of Firearm Used in Suicides: Findings From 13 States in the National Violent Death Reporting System, 2005-2015

PURPOSE

Although household firearm ownership has been consistently associated with increased suicide rates in the U.S., scant data speak to the type of gun used in U.S. suicides. We address this research gap using data from the National Violent Death Reporting System Restricted Access Data Set, 2005-2015, by describing the types of guns used in firearm suicides over time, by urban versus rural residence, for the population as a whole, and separately among adolescents, and by sex, race, and age.

METHODS

The types of firearm used by 44,540 firearm suicide decedents in 13 states from 2005 to 2015 are based on individual-level data from the National Violent Death Reporting System and urban-rural classification schemes from the National Center for Health Statistics. Rates are calculated using population data from the National Center for Health Statistics' CDC WONDER online database.

RESULTS

Between 2005 and 2015, suicide rates by handguns, but not long guns, increased markedly in both urban and rural counties. Among adolescents, handgun suicide rates doubled over the study period in both rural and urban areas; long gun suicide rates increased modestly. Although handguns were used in nearly three fourths of firearm suicides for the population as a whole, long gun use was relatively higher in rural counties and among adolescents. In rural counties, long guns were used in 51% of adolescent male suicides.

CONCLUSIONS

Suicide prevention efforts that advise gun-owning families to reduce access to household firearms should focus not only on handguns but also on long guns, especially in rural areas and among households with adolescents.

What I have is what I am: Differences in demographics, suicidal thoughts and behaviors, and firearm behavior and beliefs between firearm owners who do and do not primarily identify as firearm owners

Non-legislative forms of means safety (i.e., safe firearm storage practices) have been promoted as a way to reduce elevated suicide risk found among firearm owners. However, evidence suggests that some firearm owners are less willing than others to engage in these practices. The current study aimed to understand factors that differentiate firearm owners' beliefs and behaviors that are relevant to suicide risk by examining differences between individuals for whom firearm ownership represents a central aspect of identity (i.e., primary firearm owners) versus firearm owners who primarily identify with some other demographic or occupational characteristic. Results of main analyses revealed that primary firearm owners were more likely to be male, were less likely to have experienced suicidal ideation, were less likely to store their firearms safely across a number of storage methods, and were less open to means safety across all storage methods. These findings highlight demographically which firearm owners may be more likely to view firearm ownership as central to their identity and also suggest that this identification may be associated with beliefs and behaviors that increase suicide risk. Future firearm suicide prevention efforts should focus on culturally competent discussions and messaging to find common ground with firearm owners and to increase the salience of suicide among firearm owners.

Firearm Ownership, Means Safety, and Suicidality

OBJECTIVE

Means safety interventions are effective at reducing suicide rates. This study examined beliefs about firearm ownership or storage and suicide risk, lifetime suicidal thoughts, and openness to means safety.

METHOD

A community sample of 107 American adult firearm owners (51.4% male; 82.2% White; _m age = 37.46) completed a series of self-report questionnaires via Amazon's Mechanical Turk.

RESULTS

Hierarchical linear regressions indicated that beliefs regarding firearm ownership or storage were associated with openness to means safety measures to prevent a suicide attempt by someone else, but not to prevent one's own suicide attempt. Additionally, results from analyses of covariance indicated that firearm owners with lifetime ideation had stronger beliefs regarding the association between firearm ownership or storage and suicide risk.

CONCLUSIONS

Findings indicate firearm owners' willingness to engage in means safety may be influenced by the degree to which they believe firearm storage is associated with suicide. Furthermore, firearm owners with prior suicide ideation are more open to the idea that firearm ownership and storage are related to suicide risk. Viewing suicide as salient to one's own life may serve as a focal point in efforts to increase openness to means safety among firearm owners.

["Armed juvenicide": youth homicides and firearms in Latin America]

This article analyzes the impact of firearms in the homicides of young people in Latin America today. A cross-sectional descriptive epidemiological study was carried out based on data from the Pan American Health Organization. There were 14,427 deaths due to assaults with firearms in young people, that is, a rate of 14.3 per 100,000 young people for the year 2014 in Latin America. Thus, 80% of all homicides in young people between 10 to 19 years of age in the region were committed with firearms. This especially affects young males, with a rate of 26.5 per 100,000 deaths due to assault with firearms, although it should not be overlooked that the deaths among women are largely femicides. In addition, 1,828 deaths of undetermined intent with firearms (especially in Argentina and Venezuela) and 284 deaths with firearms in legal interventions (showing higher policy lethality among young people) were registered. The corrected rate is therefore 16.4 young people killed by others with firearms per 100,000 youth in Latin America. The need for gun control and disarmament policies, de-stigmatization campaigns and youth development programs is discussed, in order to reduce the current conditions that foster and invisibilize the so-called "armed juvenicide" in Latin America.

Probing the Irritability-Suicidality Nexus

Suicide is a major public health concern.¹ Although still rare in absolute numbers, suicide is the second cause of death in adolescents and seems to be on the rise.² One of the strongest risk factors for suicide is suicidality (ie, suicide ideation and attempts) alongside depression, substance abuse and, of course, access to lethal means.^3-5 Identifying modifiable early predictors of suicidality and suicide should therefore be a priority for mental health researchers. In this issue of the Journal, Orri et al. examine whether distinct childhood trajectories of irritability, one of the most common symptoms across psychiatric disorders in youth, are associated with suicidality in adolescence.⁶.

Deadly Experience: The Association Between Firing a Gun and Various Aspects of Suicide Risk

Firearms account for half of all U.S. suicide deaths, but research on mechanisms through which firearms confer risk is limited. Although research has indicated firearm ownership and the unsafe storage of firearms are associated with an elevated risk of suicide, such research cannot provide insight into the extent to which a history of using a gun plays a role. We recruited a community sample (N = 100; 76% female; 44% Black) oversampled for prior suicidal behavior in a high gun ownership state (Mississippi). Consistent with hypotheses, a greater number of lifetime experiences of firing a gun were associated with elements of the capability for suicide (fearlessness about death, pain tolerance, pain persistence) and lifetime suicide attempts, but not with suicide ideation or simple pain detection. These findings indicate that guns may confer risk of suicide in part through increased comfort and aptitude with the weapon, a notion consistent with the construct of practical capability. Furthermore, these findings are consistent with research indicating that guns do not cause healthy individuals to become suicidal, but rather increase risk among already suicidal individuals. Overall, our findings highlight the importance of considering practical experience with guns as well as simple ownership and storage methods.

Openness to firearm storage safety as a suicide prevention tool among those exposed to suicide: The role of perceived closeness to the suicide decedent

BACKGROUND

Exposure to suicide and closeness to a suicide decedent may be relevant to means safety, especially in firearm owners. This study examines how such factors are associated with firearm owners' current firearm storage methods and openness to changing storage methods.

METHOD

300 firearm owners completed a survey on Amazon's Mechanical Turk program; 176 participants reported being exposed to suicide. Perceived closeness was rated as Not at all close, Close, or Extremely Close.

RESULTS

Those exposed to suicide were more open to secure storage and temporarily storing the firearm with a trusted individual to prevent someone else's suicide. Those close to the suicide decedent were more likely to use secure storage practices, more open to using secure storage methods to prevent their own and someone else's suicide, and had a higher degree of storage methods in place compared to those not close to the decedent.

LIMITATIONS

The sample may not be representative of all American firearm owners exposed to suicide.

CONCLUSIONS

Being close to a suicide decedent may influence firearm owners' current storage practices and openness to changing storage methods. Such individuals may better relate to the suicide decedent and realize the significance of using secure storage methods to prevent suicide.

Rethinking Lethality in Youth Suicide Attempts: First Suicide Attempt Outcomes in Youth Ages 10 to 24

OBJECTIVE

Although suicide is the second most frequent cause of death in American youth, suicide research has heretofore been confined to convenience samples that represent neither psychiatric nor general populations and that fail to include individuals dying at their first attempts. These limitations were addressed by assembling a youth cohort followed from the first medically recorded attempt (index attempt [IA]). It was hypothesized this approach would more accurately represent the prevalence of completed suicide after an attempt and underscore lethality based on method.

METHOD

This study draws from a previously reported retrospective-prospective all-age cohort identified through the Rochester Epidemiology Project. The original 1,490-subject sample included 813 Olmsted County youth 10 to 24 years old (n = 258 male, n = 555 female; 54.6% of total cohort) with IAs from January 1, 1986 through December 31, 2007 and followed until December 31, 2010.

RESULTS

Twenty-nine of 813 subjects (3.6%) killed themselves during the study period, with 28 of 29 dying before their 25th birthday and 20 of 28 (71.4%) dying at their first attempt. Despite composing only 31.7% of the cohort (258 of 813), male subjects composed most suicides: 23 of 29 (79.3% of suicides; 8.9% of male subjects) versus 6 of 29 female subjects (20.7% of suicides; 1.1% of female subjects). Eighty-five percent of all IA deaths involved firearms. More than a third of youth-41.2%-lacked a psychiatric history prior to IA.

CONCLUSION

These data show that more than half the IAs occurred in youth, with approximately three-fourths of completed youth suicides occurring at the IAs. In parsing cause of IA death in the all-age cohort, the contribution of firearms figured even more prominently in the subsample of youth (85.0%) than in those at least 25 years old (64.3%). The high IA lethality suggests that prevention efforts commencing after the IA are too late for most victims.

Firearm storage and shooting experience: Factors relevant to the practical capability for suicide

The capability for suicide is posited to facilitate the relatively rare transition from suicidal ideation to suicidal behavior, although the operational definition of the construct continues to evolve. The Three Step Theory proposes that capability is multifaceted and includes practical capability for suicide, defined as comfort with and access to lethal means. Empirical examinations of this construct are thus far limited. Two previous studies have examined the association between firearm storage and shooting experience and common measures of capability for suicide. This study expands the generalizability of previous findings by investigating the relationship between capability for suicide, firearm storage practices, and experience shooting a firearm in a sample of 300 American firearm owners. We found that individuals who store their firearms unsafely (loaded, in a non-secure location, or without a locking device) and who have greater experience shooting firearms have significantly higher capability for suicide. These findings extend the evidence for the construct of practical capability as it relates to firearms and highlight the need for firearm-specific means safety measures to prevent suicide.

Addressing the Cultural Challenges of Firearm Restriction in Suicide Prevention: A Test of Public Health Messaging to Protect Those at Risk

OBJECTIVES

Reducing access to firearms as a suicide prevention strategy is limited in the US today because of divergent cultural attitudes and political contentiousness surrounding gun restrictions. This research examined the effects of culturally-specific suicide prevention messages on the likelihood of restricting firearm access during periods of suicide risk.

METHODS

Focus groups and key informant interviews were conducted with rural gun owners in order to develop a suicide prevention message that highlighted the importance of restricting access to firearms during periods of risk without threatening second amendment concerns. The effectiveness of this gun culture message, relative to standard suicide prevention messaging and a control condition, was then tested with a national sample of gun owners.

RESULTS

Relative to all other conditions, respondents who received our culturally-specific message in conjunction with standard suicide prevention content reported the greatest likelihood of taking steps to restrict access to firearms. This tendency was enhanced for individuals who were more politically conservative, lived in more rural areas, and supported gun rights to a stronger degree.

CONCLUSIONS

Findings underscore the importance of attending to cultural factors in public health messaging. Messaging that respects the values of gun owners could hold promise in promoting firearm restriction for suicide prevention.

Firearm Storage in Gun-Owning Households with Children: Results of a 2015 National Survey

Data from a nationally representative probability-based online survey sample of US adults conducted in 2015 (n = 3949, response rate 55%) were used to assess self-reported gun storage practices among gun owners with children. The presence of firearms and children in the home, along with other household and individual level characteristics, was ascertained from all respondents. Questions pertaining to household firearms (how guns are stored, number, type, etc.) were asked only of those respondents who reported that they personally owned a gun. We found that approximately one in three US households contains at least one firearm, regardless of whether children lived in the home (0.34 [0.29-0.39]) or not (0.35 [0.32-0.38]). Among gun-owning households with children, approximately two in ten gun owners store at least one gun in the least safe manner, i.e., loaded and unlocked (0.21 [0.17-0.26]); three in ten store all guns in the safest manner, i.e., unloaded and locked (0.29, [0.24-0.34]; and the remaining half (0.50 [0.45-0.55]) store firearms in some other way. Although firearm storage practices do not appear to vary across some demographic characteristics, including age, sex, and race, gun owners are more likely to store at least one gun loaded and unlocked if they are female (0.31 [0.23-0.41]) vs. male (0.17 [0.13-0.22]); own at least one handgun (0.27 [0.22-0.32] vs. no handguns (0.05 [0.02-0.15]); or own firearms for protection (0.29 [0.24-0.35]) vs. do not own for protection (0.03 [0.01-0.08]). Approximately 7% of US children (4.6 million) live in homes in which at least one firearm is stored loaded and unlocked, an estimate that is more than twice as high as estimates reported in 2002, the last time a nationally representative survey assessed this outcome. To the extent that the high prevalence of children exposed to unsafe storage that we observe reflects a secular change in public opinion towards the belief that having a gun in the home makes the home safer, rather than less safe, interventions that aim to make homes safer for children should address this misconception. Guidance alone, such as that offered by the American Academy of Pediatrics, has fallen short. Our findings underscore the need for more active and creative efforts to reduce children's exposure to unsafely stored firearms.

The Association Between Gun Ownership and Statewide Overall Suicide Rates

An extensive body of research has demonstrated an association between gun ownership and suicide that extends beyond the effects of a range of covariates. We aimed to expand on extant research by examining the extent to which gun ownership predicts statewide overall suicide rates beyond the effects of demographic, geographic, religious, psychopathological, and suicide-related variables. By extending the list of covariates utilized, considering those covariates simultaneously, and using more recent data, we sought to present a more stringent test. Gun ownership predicted statewide overall suicide rates, with the full model accounting for more than 92% of the variance in statewide suicide rates. The correlation between firearm suicide rates and the overall suicide rate was significantly stronger than the correlation between nonfirearm suicide rates and the overall suicide rate. These findings support the notion that access to and familiarity with firearms serves as a robust risk factor for suicide. Therefore, means safety efforts aimed at reducing accessibility and increasing safe storage of firearms would likely have a dramatic impact on statewide overall suicide rates.

Firearm Storage in Homes With Children With Self-Harm Risk Factors

OBJECTIVES

To describe firearm storage practices in homes with children who have versus do not have self-harm risk factors.

METHODS

A cross-sectional analysis of a nationally representative probability-based online survey of US adults conducted in 2015 (n = 3949; response rate 55%). Respondents self-reported whether they lived with children and were a caretaker/health care decision-maker for a child. Household firearm ownership was ascertained for all respondents; how firearms were stored in homes with guns was asked of gun owning respondents only; all respondents were asked whether their child had a history of the following self-harm risk factors: depression, mental health conditions other than depression, or attention-deficit/hyperactivity disorder.

RESULTS

Household firearms were present in 43.5% (95% confidence interval [CI]: 34.4-64.7) of homes with children who had a history of self-harm risk factors (n = 52), compared with 42.3% (95% CI: 35.2-49.7) of homes in which no child had self-harm risk factors (n = 411). Among parents or caretakers with firearms, 34.9% (95 % CI: 20.2-53.2) stored all guns locked and unloaded when they had a child with a history self-harm risk factors, compared with 31.8% (95% CI: 25.9-38.3) when none of their children had such a history.

CONCLUSIONS

Millions of US children live in homes in which firearms are left loaded or unlocked or both. A child's history of depression, mental health conditions other than depression, or attention-deficit/hyperactivity disorder does not appear to appreciably influence caretaker decisions about whether to (1) have firearms in the home, or (2) store all household firearms in accordance with American Academy of Pediatrics recommendations (ie, locked and unloaded).

Rising longitudinal trajectories in suicide rates: The role of firearm suicide rates and firearm legislation

Firearms account for approximately half of all US suicide deaths each year despite being utilized in only a small minority of suicide attempts. We examined the extent to which overall suicide rates fluctuated relative to firearm and non-firearm suicide rates across a period of 16years (1999-2015). We further tested the notion of means substitution by examining the association between firearm suicide rates and non-firearm suicide rates. Lastly, we examined the extent to which the presence of specific laws related to handgun ownership previously shown cross-sectionally to be associated with lower suicide rates (universal background checks, mandatory waiting periods) were associated with an attenuated trajectory in suicide rates across the study period. As anticipated, whereas decreases in firearm suicide rates were associated with decreases in overall suicide rates (b=0.46, SE=0.07, p<0.001), decreases in firearm suicides were not associated with off-setting increases in suicides by other methods (b=-0.04, SE=0.05, p=0.36). Furthermore, the absence of universal background check (b=0.12, SE=0.05, p=0.028) and mandatory waiting period (b=0.16, SE=0.06, p=0.008) laws was associated with a more steeply rising trajectory of statewide suicide rates. These results mitigate concerns regarding means substitution and speak to the potential high yield impact of systematically implemented means safety prevention efforts focused on firearms.

Differentiating suicide decedents who died using firearms from those who died using other methods

Studies have documented a link between gun ownership and suicide, but little is known about characteristics of those most likely to use a gun in a suicide attempt rather than alternative methods. We examined which factors differentiate suicide decedents who died using a gun from those who died by other methods. We further examined whether such findings are consistent within the subcomponent of our larger sample comprised entirely of gun owning suicide decedents. Data reflect 267 suicide decedents, with data provided by individuals who identified as having lost someone to suicide (loss survivors). Within the full sample, a higher proportion of gun-owning and male suicide decedents died by firearm. Further, individuals who had previously discussed suicide or engaged in one or more non-lethal suicide attempts were less likely to die by suicide using a gun. Within the subsample of gun owning suicide decedents, a greater proportion of decedents who stored guns at home and in unsecure locations died from self-inflected gunshot wounds. These findings add clarity to the relationship between firearm ownership and death by suicide at the individual level. Furthermore, these findings are consistent with the notion that means safety implementation may represent a vital suicide prevention tool.

Handgun Legislation and Changes in Statewide Overall Suicide Rates

OBJECTIVES

To examine the extent to which 4 laws regulating handgun ownership were associated with statewide suicide rate changes.

METHODS

To test between-group differences in statewide suicide rate changes between 2013 and 2014 in all 50 states and the District of Columbia with and without specific laws, we ran analyses of covariance.

RESULTS

We found significant differences in suicide rate changes from 2013 to 2014 in states with mandatory waiting periods and universal background checks relative to states without such laws. States with both laws differed significantly from those with neither. No significant differences in rate changes were noted for open carry restrictions or gun lock requirements.

CONCLUSIONS

Some state laws regulating aspects of handgun acquisition may be associated with lower statewide suicide rates. Laws regulating handgun storage and carrying practices may have a smaller effect, highlighting that legislation is likely most useful when its focus is on preventing gun ownership rather than regulating use and storage of guns already acquired. Public Health Implications. The findings add to the increasing evidence in support of a public health approach to the prevention of suicide via firearms, focusing on waiting periods and background checks.

Reducing a suicidal person's access to lethal means of suicide: a research agenda

Reducing the availability of highly lethal and commonly used suicide methods has been associated with declines in suicide rates of as much as 30%-50% in other countries. The theory and evidence underlying means restriction is outlined. Most evidence of its efficacy comes from population-level interventions and natural experiments. In the U.S., where 51% of suicides are completed with firearms and household firearm ownership is common and likely to remain so, reducing a suicidal person's access to firearms will usually be accomplished not by fiat or other legislative initiative but rather by appealing to individual decision, for example, by counseling at-risk people and their families to temporarily store household firearms away from home or otherwise making household firearms inaccessible to the at-risk person until they have recovered. Providers, gatekeepers, and gun owner groups are important partners in this work. Research is needed in a number of areas: communications research to identify effective messages and messengers for "lethal means counseling," clinical trials to identify effective interventions, translational research to ensure broad uptake of these interventions across clinical and community settings, and foundational research to better understand method choice and substitution. Approaches to suicide methods other than firearms are discussed. Means restriction is one of the few empirically based strategies to substantially reduce the number of suicide deaths.

Associations between changes in the pattern of suicide methods and rates in Korea, the US, and Finland

BACKGROUND

The lethality of the suicide method employed is a strong risk factor for the completion of suicide. We examined whether annual changes in the pattern of suicide methods is related to annual changes in suicide rates in South Korea, the United States (US), and Finland.

METHODS

We analyzed annual data from 2000-2011 for South Korea and Finland, and 2000-2010 for the US in order to examine trends in the rates and methods of suicide. Data on suicide methods were obtained from the World Health Organization (WHO) mortality database.

RESULTS

Along with an annual rapid increase in suicide rates, the incidence of hanging increased steadily while suicide by self-poisoning steadily decreased in South Korea. In the US, along with an annual increase in suicide rates, the proportion of suicides committed by hanging increased while those committed with the use of firearms steadily decreased. In Finland, annual changes in the suicide rate and suicide method were not statistically significant during the study period.

CONCLUSIONS

Our present findings suggest that the increased use of specific lethal methods for suicide, namely hanging, is reflected in the increased suicide rates in the Korean and the US populations. The most effective approach for reducing overall suicide rates may be the implementation of population-based initiatives that reduce both the accessibility (e.g., access to firearms) and the social acceptability (e.g., effective and responsible regulations for reporting suicide) of lethal methods of suicide.

Explaining geographic patterns of suicide in the US: the role of firearms and antidepressants

Background

Suicide rates vary more than 3-fold across the fifty states. Previous ecological studies have pointed, separately, to covariation of suicide mortality with rates of a) household firearm ownership, and b) antidepressant prescriptions.

Methods

An ecologic study using panel data from 2001-2005 was used to evaluate the joint and separate association of household firearm ownership and antidepressant prescription rates with the distribution of suicide rates across the United States. Key exposures were household firearm ownership prevalence (using data from the 2004 Behavioral Risk Factor Surveillance System) and antidepressant prescription rates (using data supplied by IMS health). Negative binomial mixed-effect models were used to estimate the association between household firearm ownership prevalence and antidepressant prescriptions rates and state level suicide rates (using data from the National Vital Statistics System), overall and by method of suicide (firearm vs. non-firearm). Sensitivity analyses examined analogous county-level data for those counties for which firearm ownership measures were available. All analyses were adjusted for median income, unemployment rate, and percent of population in urban areas.

Results

In adjusted analyses, household firearm prevalence is significantly associated with overall suicide rates (adjusted incidence rate ratio (IRRa) = 1.28, 95% confidence interval (CI): 1.18, 1.38) and firearm suicides rates (IRRa = 1.61, CI: 1.45, 1.80), but not with non-firearm suicide rates (IRRa = 1.05, 95% CI: 0.95, 1.16). By contrast, adjusted analyses find no relationship between suicide rates and antidepressant prescription rates. Findings from county-level analyses were consistent with state-level results.

Conclusion

The prevalence of household firearm ownership is strongly and significantly associated with overall suicide rates, due to its association with firearm suicide rates. This association is robust to consideration of the role of antidepressant prescription rates. A relationship between antidepressant prescription rates and suicide rates was not observed before or after adjusting for firearm ownership.

Association of suicide rates, gun ownership, conservatism and individual suicide risk

OBJECTIVES

The purpose of the study was to examine the association of suicide rates, firearm ownership, political conservatism, religious integration at the state level, and individual suicide risk. Social structural and social learning and social integration theories were theoretical frameworks employed. It was hypothesized that higher suicide rates, higher state firearm availability, and state conservatism elevate individual suicide risk.

METHOD

Data were pooled from the Multiple Cause of Death Files. Multilevel logistic regression models were fitted to all deaths occurring in 2000 through 2004 by suicide.

RESULTS

The state suicide rate significantly elevated individual suicide risk (AOR = 1.042, CI = 1.037, 1.046). Firearm availability at the state level was associated with significantly higher odds of individual suicide (AOR = 1.004, CI = 1.003, 1.006). State political conservatism elevated the odds of individual suicides (AOR = 1.005, CI = 1.003, 1.007), while church membership at the state level reduced individual odds of suicide (AOR = 0.995, CI = 0.993, 0.996). The results held even after controlling for socioeconomic and demographic variables at the individual level.

CONCLUSION

It was concluded that the observed association between individual suicide odds and national suicide rates, and firearm ownership cannot be discounted. Future research ought to focus on integrating individual level data and contextual variables when testing for the impact of firearm ownership. Support was found for social learning and social integration theories.

Analysis of 16 years of homicides and suicides involving the use of weapons recorded at the Milan Medicolegal Bureau

The criminal use of weapons is a very topical issue in the industrialized countries and worldwide, and a reconsideration of the legislation governing their possession is warranted. We retrospectively analyzed the homicides and suicides involving the use of firearms and piercing and/or cutting weapons recorded at the Medicolegal Bureau in Milan from January 1, 1993, to December 31, 2008. First we considered the clinical histories of the deceased and the circumstantial details of their deaths, then we examined the data relating to the cause of death recorded in the autopsy reports. Our case series consisted of 414 homicides (54.2%) and 350 suicides (45.8%). Firearms were responsible for more deaths (64%) than piercing and/or cutting weapons (36%). The firearms involved were legally licensed in 40% of cases (suicides) and illegal in 22% (homicides). Our findings suggest the need to review the criteria considered for the issue of firearms licenses, in Italy at least.

Suicide among children and adolescents in Canada: trends and sex differences, 1980-2008

BACKGROUND

Suicide is the second leading cause of death for young Canadians (10-19 years of age)--a disturbing trend that has shown little improvement in recent years. Our objective was to examine suicide trends among Canadian children and adolescents.

METHODS

We conducted a retrospective analysis of standardized suicide rates using Statistics Canada mortality data for the period spanning from 1980 to 2008. We analyzed the data by sex and by suicide method over time for two age groups: 10-14 year olds (children) and 15-19 year olds (adolescents). We quantified annual trends by calculating the average annual percent change (AAPC).

RESULTS

We found an average annual decrease of 1.0% (95% confidence interval [CI] -1.5 to -0.4) in the suicide rate for children and adolescents, but stratification by age and sex showed significant variation. We saw an increase in suicide by suffocation among female children (AAPC = 8.1%, 95% CI 6.0 to 10.4) and adolescents (AAPC = 8.0%, 95% CI 6.2 to 9.8). In addition, we noted a decrease in suicides involving poisoning and firearms during the study period.

INTERPRETATION

Our results show that suicide rates in Canada are increasing among female children and adolescents and decreasing among male children and adolescents. Limiting access to lethal means has some potential to mitigate risk. However, suffocation, which has become the predominant method for committing suicide for these age groups, is not amenable to this type of primary prevention.

Disparities in firearms ownership and storage practices in North Carolina

OBJECTIVE

Because household firearms pose a risk to children, this study examined firearms accessibility in North Carolina households with children.

METHODS

In 2008, parents completing the North Carolina Child Health Assessment and Monitoring Program survey were asked how many firearms they owned and their firearms storage practices. Weighted analyses provided estimates of ownership and storage practices and examined variation by sociodemographics.

RESULTS

A total of 37% of 2885 parents reported owning firearms. Whites (adjusted odds ratio [aOR] 3.9 [95% confidence interval {CI} 2.9-5.2]), households with income >200% of the federal poverty level (aOR 1.7 [95% CI 1.2-2.5]) and married parents (aOR 2.4 [95% CI 1.8-3.4]) were more likely to own firearms. Ownership of more than one firearm was greater among whites (aOR 2.2 [95% CI 1.4-3.4]) and married parents (aOR 1.8 [95% CI 1.5-2.8]) than other groups. The number of firearms owned increased with children's age. Although most parents reported keeping firearms locked and unloaded (57%), many reported unsafe storage practices, which varied by race/ethnicity. Whites were more likely (45%) to store firearms unlocked and/or loaded than other groups (35%).

CONCLUSIONS

Many North Carolina youth have access to household firearms, with white youth being more likely to have firearms, a greater number of firearms, and less safely stored firearms than other race/ethnicity groups. Further interventions and policies to reduce youth access to household firearms are needed. Future research should examine and address why whites, married couples, and those with socioeconomic advantages are more likely than individuals not belonging to these groups to own household firearms and store them unsafely.

Improving firearm storage in Alaska native villages: a randomized trial of household gun cabinets

OBJECTIVES

We determined if the installation of gun cabinets improved household firearm storage practices.

METHODS

We used a wait list, randomized trial design with 2 groups. The "early" group received the intervention at baseline, and the "late" group received it at 12 months. Up to 2 gun cabinets were installed in each enrolled home, along with safety messages. In-person surveys were conducted at 12 and 18 months to determine the proportion of households reporting unlocked guns or ammunition. Direct observations of unlocked guns were also compared.

RESULTS

At baseline, 93% of homes reported having at least 1 unlocked gun in the home, and 89% reported unlocked ammunition. At 12 months, 35% of homes in the early group reported unlocked guns compared with 89% in the late group (P < .001). Thirty-six percent of the early homes reported unlocked ammunition compared with 84% of late homes (P < .001). The prevalence of these storage practices was maintained at 18 months. Observations of unlocked guns decreased significantly (from 20% to 8%) between groups (P < .03).

CONCLUSIONS

Gun cabinet installation in rural Alaskan households improved the storage of guns and ammunition. If these gains are sustained over time, it may lead to a reduction in gun-related injuries and deaths in this population.

Veterans and suicide: a reexamination of the National Death Index-linked National Health Interview Survey

OBJECTIVES

We assessed the risk of suicide among veterans compared with nonveterans.

METHODS

Cox proportional hazards models estimated the relative risk of suicide, by self-reported veteran status, among 500,822 adult male participants in the National Death Index (NDI)-linked National Health Interview Survey (NHIS), a nationally representative cohort study.

RESULTS

A total of 482 male veterans died by suicide during 1,837,886 person-years of follow-up (76% by firearm); 835 male nonveterans died by suicide during 4,438,515 person-years of follow-up (62% by firearm). Crude suicide rates for veterans and nonveterans were, respectively, 26.2 and 18.8 per 100,000 person-years. The risk of suicide was not significantly higher among veterans, compared with nonveterans, after adjustment for differences in age, race, and survey year (hazard ratio = 1.11; 95% confidence interval = 0.96, 1.29).

CONCLUSIONS

Consistent with most studies of suicide risk among veterans of conflicts before Operation Iraqi Freedom/Operation Enduring Freedom, but in contrast to a previous study using the NDI-linked NHIS data, we found that male veterans responding to the NHIS were modestly, but not significantly, at higher risk for suicide compared with male nonveterans.

Suicide mortality in the United States: the importance of attending to method in understanding population-level disparities in the burden of suicide

Suicide mortality varies widely across age, sex, race, and geography, far more than does mortality from the leading causes of natural death. Unlike the tight correlation between cancer mortality and the incidence of cancer, suicide mortality is only modestly correlated with the incidence of suicidal acts and other established risk factors for suicidal behavior, such as major psychiatric disorders. An implication of this modest correlation is that the proportion of all suicidal acts that prove fatal (the case fatality ratio) must account for a substantial portion of the (nonrandom) variation observed in suicide mortality. In the United States, the case fatality ratio is strongly related to the availability of household firearms. Findings from ecologic and individual-level studies conducted over the past two decades illustrate the importance of accounting for the availability of highly lethal suicide methods in efforts to understand (and ultimately reduce) disparities in suicide mortality across populations.

Elevated suicide rates at high altitude: sociodemographic and health issues may be to blame

Suicide rates are higher at high altitudes; some hypothesize that hypoxia is the cause. We examined 8,871 suicides recorded in 2006 in 15 states by the National Violent Death Reporting System, with the victim's home county altitude determined from the National Elevation Dataset through FIPS code matching. We grouped cases by altitude (low<1000m; middle=1000-1999m; high≥2000m). Of reported suicides, 5% were at high and 83% at low altitude, but unadjusted suicide rates per 100,000 population were higher at high (17.7) than at low (5.7) altitude. High and low altitude victims differed with respect to race, ethnicity, rural residence, intoxication, depressed mood preceding the suicide, firearm use and recent financial, job, legal, or interpersonal problems. Even after multivariate adjustment, there were significant differences in personal, mental health, and suicide characteristics among altitude groups. Compared to low altitude victims, high altitude victims had higher odds of having family or friends report of a depressed mood preceding the suicide (OR 1.78; 95%CI:1.46-2.17) and having a crisis within 2weeks before death (OR 2.00; 95%CI:1.63-1.46). Suicide victims at high and low altitudes differ significantly by multiple demographic, psychiatric, and suicide characteristics; these factors, rather than hypoxia or altitude itself, may explain increased suicide rates at high altitude.

Suicidal behavior and firearm access: results from the second injury control and risk survey

The association between home firearms and the likelihood and nature of suicidal thoughts and plans was examined using the Second Injury Control and Risk Survey, a 2001-2003 representative telephone survey of U.S. households. Of 9,483 respondents, 7.4% reported past-year suicidal thoughts, 21.3% with a plan. Similar proportions of those with and without a home firearm reported suicidal thoughts, plans, and attempts. Among respondents with suicidal plans, the odds of reporting a plan involving a firearm were over seven times greater among those with firearms at home, compared with those without firearms at home. The results suggest people with home firearms may not be more likely to be suicidal, but when suicidal they may be more likely to plan suicide by firearm.

Suicide by firearms on the island of Crete: a 9-year record

BACKGROUND

Whereas firearm suicide mortality has been a longstanding public concern worldwide, in Greece no systematic analysis has been reported so far despite the recent evidence of a rising rate of gun ownership.

AIMS

To estimate the proportion of firearm suicides on the island of Crete, Southern Greece, well-known for its widespread gun ownership; to describe the victims' sociodemographic profile and firearm-related suicide variables; and to assess the severity of suicidal intention in the group.

METHODS

Records of suicides between 1999 and 2007 were reviewed and information was extracted into a computerized database. A rating of the circumstances section of the Beck's Suicide Intent Scale (SIS) for each case was also performed.

RESULTS

The firearm suicide rate was 1.3 per 100,000, with males constituting the vast majority. These men were more likely to be less than 55 years of age, to have lived in the western part of the island, to have some degree of planning prior to the suicidal act, and to have used a shotgun, but less likely to have left a note.

CONCLUSIONS

As an important first step toward implementing preventive initiatives the authors stress the need for a thorough look at the sociocultural factors associated with firearms in the region.

Characteristics of police officer suicides in the Federal Austrian Police Corps

BACKGROUND

Suicide rates among police officers may be high because of strong occupational stressors.

AIMS

This study examined the suicide rate and suicide characteristics among police officers in the Federal Austrian Police Force.

METHODS

All suicides among policemen during the period 1996-2006 were analyzed retrospectively on the basis of personalized police record files from all Austrian police departments. Information on sex, age, marital status, children, region, method and place of suicide, suicide notes, position, and length of service was extracted from these files. The general Austrian population, adjusted for sex and age composition, served as the comparison group.

RESULTS

The suicide rate among male police officers was 30.2/100,000 (SD 11.0), which was comparable to the suicide rate in the adjusted general population (30.5/100,000; SD 2.9). The female police officer suicide rate was 1.8/100,000, while the corresponding suicide rate of the adjusted female general population was 12.5/100,000 (SD 1.7). Firearms were the most frequent suicide method (77.8%), and the incidence of suicide notes was 30.8%.

CONCLUSIONS

Suicide rates among police officers seem comparable to those of the age-adjusted general population. Given the healthy-worker effect, these results still suggest an increased risk of suicide among police officers. These findings should stimulate further research on stressors and risk factors for suicide among officers and should also encourage departments to increase awareness regarding suicidal signs among officers.