Impact of Firearm Availability and Gun Regulation on State Suicide Rates

How to find nothing 2.0

Various problematic statistical approaches can be used in regression analyses to help find no significant relationship between explanatory variables and response variables-"to find nothing." In an earlier paper, I provided examples of finding nothing from firearm studies, focusing on the lack of statistical power. In this Viewpoint, I offer three examples of "finding nothing" from firearms research and focus on a single hypothesis-that household gun ownership levels affect suicide rates, examining one type of evidence-cross-sectional ecological studies. I discuss studies examining variations in suicide rates across US states, US cities, and nations, highlighting the work of the one firearm researcher who continually "finds nothing."

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.

How firearm legislation impacts firearm mortality internationally: A scoping review

Background

The literature on gun violence is broad and variable, describing multiple legislation types and outcomes in observational studies. Our objective was to document the extent and nature of evidence on the impact of firearm legislation on mortality from firearm violence.

Methods

A scoping review was conducted under PRISMA-ScR guidance. A comprehensive peer-reviewed search strategy was executed in several electronic databases from inception to March 2024. Grey literature was searched for unpublished sources. Data were extracted on study design, country, population, type of legislation, and overall study conclusions on legislation impact on mortality from suicide, homicide, femicide, and domestic violence. Critical appraisal for a sample of articles with the same study design (ecological studies) was conducted for quality assessment.

Findings

5057 titles and abstracts and 651 full-text articles were reviewed. Following full-text review and grey literature search, 202 articles satisfied our eligibility criteria. Federal legislation was identified from all included countries, while state-specific laws were only reported in studies from the U.S. Numerous legislative approaches were identified including preventative, prohibitive, and more tailored strategies focused on identifying high risk individuals. Law types had various effects on rates of firearm homicide, suicide, and femicide. Lack of robust design, uneven implementation, and poor evaluation of legislation may contribute to these differences.

Interpretation

We found that national, restrictive laws reduce population-level firearm mortality. These findings can inform policy makers, public health researchers, and governments when designing and implementing legislation to reduce injury and death from firearms.

Funding

Funding is provided by the Strategy for Patient-Oriented Research (SPOR) Evidence Alliance and in part by St. Michael's Hospital, University of Toronto.

Scoping review registration

Open Science Framework (OSF): https://osf.io/sf38n.

Black and White Demographic Patterns of Gun Ownership and Suicide, 2021

OBJECTIVE

We use 2021 data to compare the demographic patterns of adult White and Black gun ownership with their respective race-specific rates of firearm, non-firearm and total suicide, and the percentage of suicides using firearms.

METHODS

Data on gun ownership came from a nationally representative sample of over 19,000 respondents to the 2021 National Firearms Survey. Both race-specific gun ownership and suicide rates were stratified by respondent demographics-sex (male, female), census region (Northeast, South, Midwest, West), urbanicity (metropolitan or non-metropolitan), and age (18-29, 30-44, 45-59, 60+).

RESULTS

White adults reported higher rates of gun ownership than did Black adults (33% vs 24%) but a firearm was used in a similar percentage of suicides (56% vs 58%). The demographic patterns of gun ownership of White and Black adults were similar-those least likely to report owning firearms were females, those living in the Northeast, residents of metropolitan areas, and younger adults. But the suicide patterns were somewhat different-whereas suicide rates among White adults were highest among older Whites and among Whites in non-metropolitan areas, suicide rates among Black adults were highest among younger Blacks and similar in metropolitan and non-metropolitan areas.

CONCLUSIONS

The self-reported levels and patterns of Black gun ownership cannot explain why such a high percentage of Black suicides are firearm suicides or why firearm and total suicide rates of Black adults fall so dramatically with age.

Substitution of Methods in Suicide Deaths - Firearm Injury and Hanging

Background: Prevention strategies for suicide emphasize restrictions on firearm access. These restrictions may lose efficacy if individuals substitute other lethal suicide methods. Aims: The objective of this study is to determine the extent to which individuals who die by suicide in the United States substitute hanging for firearm injury. Methods: This study is a repeated cross-sectional analysis of suicide deaths in the United States from 2003 to 2021. Multiple regression was used to estimate the effect of firearm access proxies on individual suicide methods (hanging vs. firearm injury). Results: The probability of death by hanging was significantly and negatively associated with proxies of firearm access. Limitations: This study does not compare crude rates of suicide by state, which rise on average with rates of firearm ownership. The National Violent Death Reporting System expanded over the sample period, so early years have incomplete ascertainment. Rates of gun ownership and gun safety law scales are measured as proxies. Conclusions: Although means restriction around firearm access is a critical tool for suicide prevention, complementary strategies for prevention around hanging merit further study.

Formative reasons for state-to-state influences on firearm acquisition in the U.S

Objectives

Firearm-related crimes and self-inflicted harms pose a significant threat to the safety and well-being of Americans. Investigation of firearm prevalence in the United States (U.S.) has therefore been a center of attention. A critical aspect in this endeavor is to explain whether there are identifiable patterns in firearm acquisition.

Methods

We view firearm acquisition patterning as a spatio-temporal dynamical system distributed across U.S. states that co-evolves with crime rates, political ideology, income levels, population, and the legal environment. We leverage transfer entropy and exponential random graph models along with publicly available data, to statistically reveal the formative factors in how each state's temporal patterning of firearm acquisition influences other states.

Results

Results help to explain how and why U.S. states influence each other in their firearm acquisition. We establish that state-to-state influences, or lack thereof, in firearm acquisition patterning are explained by states' percent of gun homicide, firearm law strictness, geographic neighborhood, and citizen ideology. Network-based characteristics, namely, mutuality and transitivity, are also important to explain such influence.

Conclusions

Results suggest that state policies or programs that reduce gun homicides will also help suppress that state's influence on the patterning of firearm acquisition in other states. Furthermore, states with stricter firearm laws are more likely to influence firearm acquisition in other states, but are themselves shielded from the effects of other states' firearm acquisition patterns. These results inform future research in public health, criminology, and policy making.

Exploratory qualitative study of firearm storage practices among surgeons in the USA: contexts and motivations

BACKGROUND

A US survey of surgeons found that 32% store firearms unlocked and loaded. This study explored conditions and contexts impacting personal firearm storage methods among surgeons.

METHODS

We conducted semi-structured interviews with English-speaking fellows of the American College of Surgeons who treated patients injured by firearms and who owned or lived in homes with firearms. Participants were recruited through email and subsequent snowball sampling from April 2022 to August 2022. All interviews were audio-recorded and transcribed verbatim. Thematic analysis was applied to transcripts to identify codes. A mixed deductive and inductive approach was used for data reduction and sorting.

RESULTS

A total of 32 surgeons were interviewed; most were male and white. Dominant themes for firearm storage practices were based on (1) attitudes; (2) perceived norms; (3) personal agency; and (4) intention of firearm use. Personal agency often conflicted with attitudes and perceived norms for surgeons owning firearms for self-defence.

CONCLUSIONS

Storage practices in this sample of firearm-owning surgeons were driven by intent for firearm use, coupled with attitudes, perceived norms and personal agency. Personal agency often conflicted with attitudes and perceived norms, especially for surgeons who owned their firearm for self-defence.

Perceptions of the utility of secure firearm storage methods as a suicide prevention tool among firearm owners who currently store their firearms loaded and unlocked

BACKGROUND

Although secure firearm storage can prevent firearm injury and death, secure storage is relatively rare. This tendency may be driven in part by a perceived lack of utility for secure storage in preventing suicide and other gun violence-related outcomes.

METHOD

We recruited a large (n = 3510) representative sample of residents from five US states and assessed the degree to which those who do and do not store their firearms securely perceive different utility in specific firearm storage practices for suicide prevention. To test for specificity, we examined if those differences hold when considering unintentional shooting and firearm theft prevention.

RESULTS

Those who currently store their firearms unsecured reported lower perceived utility in several firearm storage practices, particularly for suicide and theft prevention.

CONCLUSIONS

Our findings highlight that a lack of perceived utility in secure firearm storage may partially drive unsecure firearm storage. Efforts to promote secure storage must address this misperception.

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.

Black Household gun ownership and black suicide rates across U.S. States

INTRODUCTION

Ecologic studies have examined the relationship across states between levels of household gun ownership and suicide rates using household gun ownership data from the Behavioral Risk Factor Surveillance System (BFRSS) or proxies. However, no study has examined how race-specific survey-based or proxy measures of gun ownership are related to race-specific suicide rates.

METHODS

We use cross-sectional state-level race-specific data to examine how well various proxies correlate with race-specific BRFSS gun ownership rates. We examine whether BRFSS measures of household gun ownership are correlated with firearm suicide, non-firearm suicide, and total suicide rates, for Black and for White adults, and repeat these assessments with select proxies. The core BRFSS only included gun questions in 2001, 2002, and 2004, but not since; mortality data are collapsed 2001-2010.

RESULTS

Among a set of proxies, the race-specific fraction of suicides that are firearm suicides (FS/S) is the measure most highly correlated with BRFSS household gun ownership. Across states, White adult BFRSS household gun ownership levels are highly correlated with White adult firearm suicide rates (correlation coefficient .82) and moderately correlated with White overall suicide rates (.63). However, for Black adults, we find that while the state-level Black gun ownership levels are moderately correlated with Black firearm suicide rates (.67)-more strongly for older (.70) than for younger (.47) Black adults-Black BRFSS gun ownership levels are only weakly correlated with Black overall suicide rates (.17) owing to a moderate inverse correlation with Black non-firearm suicide rates (-.45). For Black adults, the relationship between FS/S and suicide is similar to the relation between BRFSS and suicide.

CONCLUSION

For White adults, states with higher levels of measured household gun ownership have higher overall suicide rates. This relationship does not hold for Black adults, largely due to a more attenuated correlation between these measures of firearm availability and firearm suicide rates coupled with a more substantial countervailing (inverse) relationship between these measures and non-firearm suicide rates. Future efforts using individual level data might help determine why this puzzling difference exists, especially for young Black adults.

Long gun suicides in the state of Maryland following the firearm safety act of 2013

OBJECTIVES

In 2013, the state of Maryland passed the Firearms Safety Act limiting the private sales of handguns, which did not apply to long guns often used for hunting (e.g., rifles and shotguns). This decreased the accessibility of handguns relative to long guns. We assessed the frequency of long gun suicides in the years before and after the policy change during winter season, which encompasses hunting season in Maryland.

METHODS

We performed a retrospective analysis on all 4107 well-characterized adult suicides caused by firearms in Maryland from 2003 through 2019. Logistic regression was performed, stratifying by decedent sex, race, and age.

RESULTS

While handgun suicides decreased in the period after 2013's Firearm Safety Act (p < 0.008), wintertime long gun suicides increased after 2013 (p < 0.004). Caucasian race (p < 0.006), male sex (p < 0.005), and middle age (p < 0.001) were significantly associated with wintertime long gun suicides after 2013.

CONCLUSION

Our findings suggest that while the 2013 Firearms Safety Act decreased handgun suicides significantly, it did not reduce long gun suicides and there may even have been replacement with long guns during hunting season, when rifles are out and accessible. This association was most prominent among the demographics most likely to hunt (Caucasian, middle-aged, and male).

Three leading suicide methods in the United States, 2017-2019: Associations with decedents' demographic and clinical characteristics

Background and aims

The U.S. suicide data show that use of lethal methods, specifically firearms and hanging/suffocation, has been increasing among young and middle-aged adults of both sexes over the past decades. In this study, we examined demographic and clinical correlates of use of firearms, hanging/suffocation, and poisoning as suicide methods among suicide decedents age 18+.

Methods

Data came from the 2017-2019 National Violent Death Reporting System (NVDRS; N = 94,454, age ≥ 18 at the time of suicide; 74,042 men and 20,412 women). We fit generalized linear models (GLMs) for a Poisson distribution with a log link to examine (1) changes in four suicide methods (firearms, hanging/suffocation, poisoning, and other) during the study period, controlling for sex and age group; and (2) correlates of firearms, hanging/suffocation, and poisoning use.

Results

In all age groups, 55% of men and 30% of women used firearms; 28% of men and 29% of women hanging/suffocation; 9% of men and 32% of women poisoning, and 8% of men and 9% of women "other" methods. Men age < 45 had higher likelihood of firearm and/or hanging/suffocation use than those age 45-64. Women age<45 also had higher likelihood of hanging/suffocation than those age 45-64. Prior suicide attempt history was associated with higher likelihood of poisoning in both sexes and hanging/suffocation in men; mental disorders/SUD were associated with higher likelihood of hanging/suffocation and poisoning in both sexes; physical health problems were associated with higher likelihood poisoning in both sexes and firearm use in men; relationship problems were associated with higher likelihood of firearm use; legal problems and job/financial/housing problems were associated with higher likelihood of hanging/suffocation in both sexes; and more crises were associated with higher likelihood of firearm use in both sexes.

Implications

The findings call for the following suicide prevention strategies: (1) restricted access to firearms; (2) improved access to mental health/substance use treatment; (3) improved long-term and palliative care services for those (mostly older adults) with physical health problems; (4) financial/housing support policies to mitigate economic hardship; and (5) more research to identify effective strategies to curtail the increasing use of firearm and hanging/suffocation among young and middle-aged adults.

Suicide Rates and Differences in Rates Between Non-Hispanic Black and Non-Hispanic White Populations in the 30 Largest US Cities, 2008-2017

OBJECTIVES

Suicide is a leading cause of death in the United States, and rates vary by race and ethnicity. An analysis of suicide across large US cities is absent from the literature. The objective of this study was to examine suicide rates among the total population, non-Hispanic Black population, and non-Hispanic White population in the United States and in the 30 largest US cities.

METHODS

We used data from the National Vital Statistics System to calculate non-Hispanic White, non-Hispanic Black, and total age-adjusted suicide rates for the 30 largest US cities and for the entire nation during 2 periods: 2008-2012 and 2013-2017. We also examined absolute and relative differences in suicide rates among non-Hispanic White populations and non-Hispanic Black populations in each city.

RESULTS

The overall age-adjusted suicide rate per 100 000 population in the United States increased significantly from 12.3 in 2008-2012 to 13.5 in 2013-2017. Total suicide rates were stable in most cities; rates increased significantly in only 1 city (Louisville), and rates decreased significantly in 2 cities (Boston and Memphis). The non-Hispanic White suicide rate was significantly higher-1.3 to 4.3 times higher-than the non-Hispanic Black suicide rate in 24 of 26 study cities during 2013-2017. From 2008-2012 to 2013-2017, non-Hispanic White suicide rates decreased significantly in 3 cities and increased significantly in 3 cities; non-Hispanic Black suicide rates increased significantly in 5 cities and decreased in none. Absolute differences in suicide rates among non-Hispanic White populations and non-Hispanic Black populations increased significantly in 1 city (Louisville) and decreased significantly in 2 cities (Memphis and Boston).

CONCLUSIONS

Our study may inform the use of evidence-based programs and practices to address population-level risk factors for suicide.

Achieving health equity in US suicides: a narrative review and commentary

Suicide rates in the United States (US) reached a peak in 2018 and declined in 2019 and 2020, with substantial and often growing disparities by age, sex, race/ethnicity, geography, veteran status, sexual minority status, socioeconomic status, and method employed (means disparity). In this narrative review and commentary, we highlight these many disparities in US suicide deaths, then examine the possible causes and potential solutions, with the overarching goal of reducing suicide death disparities to achieve health equity.The data implicate untreated, undertreated, or unidentified depression or other mental illness, and access to firearms, as two modifiable risk factors for suicide across all groups. The data also reveal firearm suicides increasing sharply and linearly with increasing county rurality, while suicide rates by falls (e.g., from tall structures) decrease linearly by increasing rurality, and suicide rates by other means remain fairly constant regardless of relative county urbanization. In addition, for all geographies, gun suicides are significantly higher in males than females, and highest in ages 51-85 + years old for both sexes. Of all US suicides from 1999-2019, 55% of male suicides and 29% of female suicides were by gun in metropolitan (metro) areas, versus 65% (Male) and 42% (Female) suicides by gun in non-metro areas. Guns accounted for 89% of suicides in non-metro males aged 71-85 + years old. Guns (i.e., employment of more lethal means) are also thought to be a major reason why males have, on average, 2-4 times higher suicide rates than women, despite having only 1/4-1/2 as many suicide attempts as women. Overall the literature and data strongly implicate firearm access as a risk factor for suicide across all populations, and even more so for male, rural, and older populations.To achieve the most significant results in suicide prevention across all groups, we need 1) more emphasis on policies and universal programs to reduce suicidal behaviors, and 2) enhanced population-based strategies for ameliorating the two most prominent modifiable targets for suicide prevention: depression and firearms.

Child access prevention legislative language and pediatric firearm injury rates

Backgroud

Firearm injuries are a significant public health problem facing young people in the USA. In 2015, a total of 16 878 people under 19 years old were injured or killed by firearms. To reduce firearm injuries, 29 states and Washington, DC have enacted child access prevention (CAP) legislation. CAP legislation is intended to reduce the likelihood of a minor obtaining a weapon and subsequent injury or death. This study evaluates the impact of CAP legislation based on language of the legislation, specifically it evaluates a relationship of the legal threshold of liability and the number of firearm injuries per capita of minors.

Methods

Data were collected from the Web-based Injury Statistics Query and Reporting System for patients less than 19 years of age who presented to emergency departments with firearm injuries in 2016. The Giffords Law Center classification was used to group states into three categories (strong/weak/no CAP) based on CAP language. Differences of firearm-related injury rates per capita were assessed.

Results

When controlling for population, states with CAP legislation had a 22% decrease in firearm injuries per capita compared with states without CAP legislation. States with ‘strong’ CAP legislation had a 41% decrease in firearm injuries per capita compared with states with ‘weak’ or no CAP legislation when controlling for population.

Conclusions

States with ‘strong’ CAP legislation had lower pediatric firearm injury rates per capita, but more complete data and further studies are needed to evaluate this relationship as well as other factors that may impact firearm injury rates.

Bang for the buck: The impact of political financial contributions on firearm law

BACKGROUND

One hundred thousand Americans are shot annually, and 39,000 die. State laws restricting firearm sales and use have been shown to decrease firearm deaths, yet little is known about what impacts their passage or repeal. We hypothesized that spending by groups that favor firearm restrictive legislation would increase new state firearm restrictive laws (FRLs) and that states increasing these laws would endure fewer firearm deaths.

METHODS

We acquired 2013 to 2018 state data on spending by groups against firearm restrictive legislation and for firearm restrictive legislation regarding lobbying, campaign, and independent and total expenditures from the National Institute on Money in State Politics. State-level political party representation data were acquired from the National Conference of State Legislatures. Mass shooting data were obtained from the Mass Shooter Database of the Violence Project, and firearm death rates were obtained from Centers for Disease Control Wide-ranging Online Data for Epidemiologic Research and Federal Bureau of Investigation Uniform Crime Reporting databases. Firearm restrictive laws were obtained from the State Firearms Law Database. A univariate panel linear regression with fixed effect for state was performed with change in FRLs from baseline as the outcome. A final multivariable panel regression with fixed effect for state was then used. Firearm death rates were compared by whether states increased, decreased, or had no change in FRLs.

RESULTS

Twenty-two states gained and 13 lost FRLs, while 15 states had no net change (44%, 26%, and 30%; p = 0.484). In multivariable regression accounting for partisan control of state government, for-firearm restrictive legislation groups outspending against-firearm restrictive legislation groups had the largest association with increased FRLs (β = 1.420; 95% confidence interval, 0.63-2.21; p < 0.001). States that gained FRLs had significantly lower firearm death rates (p < 0.001). Relative to states with no change in FRLs, states that lost FRLs had an increase in overall firearm death of 1 per 100,000 individuals. States that gained FRLs had a net decrease in median overall firearm death of 0.5 per 100,000 individuals.

CONCLUSION

Higher political spending by groups in favor of restrictive firearm legislation has a powerful association with increasing and maintaining FRLs. States that increased their FRLs, in turn, showed lower firearm death rates.

LEVEL OF EVIDENCE

Epidemiological, level I.

Public guns, private violence: The association of city-level firearm availability and intimate partner homicide in the United States

This city-level study examines the association of federally licensed firearm dealers (FFLs) and measures of illegal firearm availability with the risk of intimate partner homicide. Annual data for a sample of 286 large cities in the United States were collected for the years 2010-2019, incorporating city-level information on the number of gun-perpetrated homicides, the rate of licensed firearm dealers, and guns reported lost or stolen. All data were compiled and analyzed in 2020. Negative binomial models were used to assess the relation of firearm availability and gun homicide by intimate partners, in comparison to gun homicide between non-intimates. Results indicate that a higher rate of licensed firearm dealers was associated with a higher risk of intimate partner homicide, although more pronounced in states with lower-than-average existing gun ownership. This association was robust to different analytical methods and alternate ways of capturing illegal guns. A supplementary analysis using unique data from The Trace further supports the argument that FFL presence is a risk factor for intimate partner firearm homicide specifically, but not necessarily firearm homicide characterized by other motives.

The Impact of Firearm Legislation on Firearm Deaths, 1991-2017

Firearm violence is a major public health concern in the USA with firearm suicide and homicide accounting for the majority of gun deaths. The present work seeks to explore the role of firearm legislation in reducing suicide and homicide rates. Using the State Firearm Law Database (www.statefirearmlaws.org), suicide and homicide rates were compared across the 50 US states from 1991 to 2017. A firearm regulations index was computed to represent the total number of state firearm laws. Generalized estimating equations were used to explore population-level increases or decreases in firearm regulations and their association with state suicide and homicide rates after controlling for several state-level covariates. Even after accounting for several key covariates (US region; time; gun ownership; percent of the state population that was White, Black, below the poverty line and 25 years or older with a bachelor's degree; incarceration rate, unemployment rate and divorce rate), we found that firearm laws significantly predicted state firearm suicide and homicide rates. States with greater numbers of laws had reduced suicide and homicide rates compared with those with fewer laws. The present findings point to the role of firearm legislation in curbing rates of gun violence across the USA.

Suicide and the agent-host-environment triad: leveraging surveillance sources to inform prevention

Suicide in the US has increased in the last decade, across virtually every age and demographic group. Parallel increases have occurred in non-fatal self-harm as well. Research on suicide across the world has consistently demonstrated that suicide shares many properties with a communicable disease, including person-to-person transmission and point-source outbreaks. This essay illustrates the communicable nature of suicide through analogy to basic infectious disease principles, including evidence for transmission and vulnerability through the agent-host-environment triad. We describe how mathematical modeling, a suite of epidemiological methods, which the COVID-19 pandemic has brought into renewed focus, can and should be applied to suicide in order to understand the dynamics of transmission and to forecast emerging risk areas. We describe how new and innovative sources of data, including social media and search engine data, can be used to augment traditional suicide surveillance, as well as the opportunities and challenges for modeling suicide as a communicable disease process in an effort to guide clinical and public health suicide prevention efforts.

Adapting Safety Check as a Universal Suicide Prevention Strategy in Pediatric Primary Care

OBJECTIVE

The presence of unlocked firearms in the home is associated with increased risk of suicide and unintentional injury in youth. We adapted an evidence-based program for promoting safe firearm storage, Safety Check, to enhance its acceptability as a universal suicide prevention strategy in pediatric primary care.

METHODS

We applied ADAPT-ITT, an established adaptation framework, to guide iterative program adaptation with ongoing input from key stakeholders. The present study describes 2 phases of ADAPT-ITT: the Production phase (generating adaptations) and the Topical Experts phase (gathering stakeholder feedback on adaptations). After generating proposed program adaptations based on 3 inputs (stakeholder feedback collected in a prior study, the behavioral science literature, and best practices in pediatric medicine), we elicited feedback from stakeholders with firearm expertise. The adaptations included changes such as clarifying firearm ownership will not be documented in the medical record and offering follow-up reminders. We also crowdsourced feedback from 337 parents to select a new name and program logo.

RESULTS

Saturation was reached with 9 stakeholders. Feedback confirmed the value of adaptations that: 1) considered context (eg, reason for ownership), 2) promoted parent autonomy in decision-making, and 3) ensured privacy. The most preferred program name was Suicide and Accident prevention through Family Education (SAFE) Firearm.

CONCLUSIONS

Guided by an established adaptation framework that prioritized multistage stakeholder feedback, adaptations to the original Safety Check were deemed acceptable. We plan to test the SAFE Firearm program as a universal suicide prevention strategy in pediatric primary care via a hybrid effectiveness-implementation trial.

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.

Suicidality among Chinese college students: A cross-sectional study across seven provinces

BACKGROUND

Although the suicide rate in China has decreased over the past 20 years, there have been reports that the younger age group has been experiencing an increased incidence of completed suicide. Given that undergraduate groups are at higher risks of suicidality, it is important to monitor and screen for risk factors for suicidal ideation and behaviors to ensure their well-being.

OBJECTIVE

To examine the risk and protective factors contributing to suicidality among undergraduate college students in seven provinces in China.

METHODS

We conducted a cross-sectional study involving 13,387 college students from seven universities in Ningxia, Shandong, Shanghai, Jilin, Qinghai, Shaanxi, and Xinjiang. Data were collected using self-report questionnaires.

RESULTS

Higher scores in the psychological strain, depression, anxiety, stress, and psychache (psychological risk factors for suicidality) and lower scores in self-esteem and purpose in life (psychological protective factors against suicidality) were associated with increased suicidality among undergraduate students in China. Demographic factors which were associated with higher risks of suicidality were female gender, younger age, bad academic results, were an only child, non-participation in school associations, and had an urban household registration. Perceived good health was protective against suicidality.

CONCLUSIONS

Knowing the common risk and protective factors for suicidality among Chinese undergraduate students is useful in developing interventions targeted at this population and to guide public health policies on suicide in China.

Firearm laws and illegal firearm flow between US states

BACKGROUND

Considerable variation in firearm legislation exists. Prior studies show an association between stronger state laws and fewer firearm deaths. We hypothesized that firearms would flow from states with weaker laws to states with stronger laws based on proximity and population.

METHODS

Crime gun trace data from 2015 to 2017 was accessed from the Bureau of Alcohol, Tobacco, Firearms and Explosives and compared with the count and composition of firearm legislation in 2015 among the contiguous 48 states. Additional independent variables included population, median household income, distance, and presence or absence of a shared border. We used Exponential Random Graph Models to identify predictors of traced firearm transfers between origin and destination states.

RESULTS

After controlling for network structure, firearm laws in origin states were associated with fewer traced firearm transfers (incidence rate ratio [IRR], 0.88; 95% confidence interval [CI], 0.83-0.93; p < 0.001). Conversely, more firearm laws in destination states were associated with more traced firearm transfers (IRR, 1.10; 95% CI, 1.06-1.15; p < 0.001). Larger population at the origin was associated with increased transfers (IRR, 1.38; 95%CI, 1.27-1.50; p < 0.001), as was larger population at the destination state (IRR, 1.45; 95% CI, 1.35-1.56; p < 0.001). Greater distance was associated with fewer transfers (for each 1,000 km; IRR, 0.35; 95% CI, 0.27-0.46; p < 0.001), and transfers were greater between adjacent states (IRR, 2.49; 95% CI, 1.90-3.27; p < 0.001).

CONCLUSION

State firearm legislation has a significant impact on gun trafficking even after controlling for network structure. States with stricter firearm legislation are negatively impacted by states with weaker regulations, as crime guns flow from out-of-state.

LEVEL OF EVIDENCE

Epidemiologic, level III.

Prevalence of long gun use in Maryland firearm suicides

BACKGROUND

Firearms account for the majority of US suicides, largely due to lethality and accessibility. Under Federal and Maryland law, long guns are less regulated than handguns which is a concern for increased suicide risk. This study uses Maryland data to ascertain the impact of long guns on suicides in the state. We hypothesize that the prevalence of long gun use among firearm suicides will be increased in rural and young populations.

METHODS

This is a cross sectional study using police and medical examiner narratives to identify firearm type involved in all 3931 Maryland gun suicides from 2003 to 2018. Proportions of firearm suicides utilizing long guns were calculated. Urban-rural differences were determined using the National Center for Health Statistics' classification system. Logistic regression was used to calculate odds ratios of long gun to handgun suicides across the urban-rural spectrum, controlling for decedent demographics.

RESULTS

From 2003 to 2018, 28.4% of Maryland gun suicides used long guns. The proportion of long guns used was highest in the most rural counties, where 51.6% of firearm suicides were by long gun, compared to 16.8% in the most urban counties. Long guns were disproportionately used by the young. For decedents 18 or younger, 44.6% used long guns, compared to 20.2% in those 65 or older. Compared to the most urban counties, firearm suicide decedents in the most rural counties were 3.74x more likely to use long guns (OR = 3.74; 95% CI 2.19, 6.40; p < .001) after adjusting for demographics, intoxication, and hunting season.

CONCLUSIONS

Long guns are used in a large proportion of Maryland firearm suicides, particularly in rural areas and disproportionately in youth suicides. Long guns must be considered as part of access to lethal means or policy strategies in efforts to reduce the burden of firearm suicide.

Firearm Storage Practices and Risk Perceptions

INTRODUCTION

During the past 2 decades, gun owners have become more likely to store household firearms loaded and unlocked, and believe that guns make homes safer rather than more dangerous.

METHODS

Self-reported household firearm storage practices were described among 2,001 gun owners in relation to whether they report that firearms make homes (1) safer, (2) more dangerous, or (3) it depends. Data were from a probability-based online survey administered in 2015 (completion rate, 55%) and analyzed in 2018.

RESULTS

Nearly 60% of gun owners said that guns make homes safer (57.6%, 95% CI=55.1%, 60.1%), 39.9% (95% CI=37.4%, 42.5%) said that it depends (on other factors), and 2.5% (95% CI=1.8%, 3.4%) said that guns make homes more dangerous. A higher proportion of gun owners who reported that they believe guns increase household safety said that they store household firearms loaded and unlocked (39.2%, 95% CI=35.9%, 42.6%), compared with those who thought guns make the home either more dangerous (3.7%, 95% CI=1.3%, 10.1%) or those who thought the effect of guns on household safety depends on additional factors (17.5%, 95% CI=14.7%, 20.7%).

CONCLUSIONS

Gun owners who are most likely to assert categorically that firearms in the home make homes safer are, as a group, far more likely to store guns in their home loaded and unlocked.

Prevention of firearm injuries with gun safety devices and safe storage: An Eastern Association for the Surgery of Trauma Systematic Review

BACKGROUND

Over 50,000 homicides and suicides occur each year. An estimated half of all US households are believed to have a firearm present, making them one of the most ubiquitous consumer products. Our goal was to determine if the manner of storage of a firearm in a home could potentially make a difference in the outcomes of intentional and unintentional injuries involving a firearm; specifically addressing the use of gun safes and devices that block/disable firearm function (trigger locks, cable locks, etc.).

METHODS

A comprehensive review of the literature was performed. We used Grading of Recommendations Assessment, Development, and Evaluation methodology to assess the breadth and quality of the data specific to our Population, Intervention, Comparator, Outcomes (PICO) questions.

RESULTS

A total of 176 studies were initially identified, then, 120 more added after a subsequent literature review, with 97 removed as duplicates. One hundred ninety-one case reports, case series, and reviews were removed because they did not focus on prevention or did not address our comparators of interest. This left a total of two studies which merited inclusion for PICO 1, should gun locks be used to prevent firearm injuries and six studies which merited inclusion for PICO 2, should safe storage for guns be used to prevent firearm injuries.

CONCLUSION

PICO 1: We conditionally recommend that gun locks be used to prevent unintentional firearm injury. PICO 2: Because of the large effect size and the reasonable quality of available evidence with safe storage of firearms, we recommend safe storage prevent firearm-related injuries.

LEVEL OF EVIDENCE

Systematic review, level III.

Master Clinician Review: Saving Holden Caulfield: Suicide Prevention in Children and Adolescents

OBJECTIVE

The rate of adolescent suicide and suicidal behavior has risen dramatically in the past decade. The title of this article comes from the classic coming-of-age novel by J.D. Salinger, The Catcher in the Rye. Its protagonist, Holden Caulfield, is a precocious adolescent who, in the face of his inability to cope with his own self-destructives urges, imagines himself saving "little kids playing some game in this big field of rye." He is standing on the edge of a cliff trying to catch "thousands of little kids" before they fall to their demise. This vignette from The Catcher in the Rye provides a useful metaphor for the relationship between mental health professionals and youth at risk for suicide, and suggests more efficient and effective alternative interventions to prevent youth suicide compared to standing by a cliff.

METHOD

These four alternative approaches are described, namely: (1) leading youth away from the cliff (ie, prevention); (2) going to where youth are (ie, improving access to care); (3) working with others to change the rules in the field (ie, changing the way care is delivered); and (4) putting a fence around the cliff (ie, restriction of access to lethal agents). The evidence to support the utility and cost-effectiveness of each of these approaches is reviewed.

CONCLUSION

There are extant, empirically supported, cost-effective approaches to the prevention and management of adolescent suicidal behavior that, if implemented widely, are likely to significantly reverse the decade-long rise in adolescent suicide.

Who owns guns and how do they keep them? The influence of household characteristics on firearms ownership and storage practices in the United States

Our paper aims to describe firearm-related behavior among American households and to quantify the influence of household characteristics on the probability of firearms possession and storage practices. Applying logistic regression techniques to data from the 2004 Behavioral Risk Factor Surveillance Survey (BRFSS), we use separate models to estimate the effect of an array of respondent demographic characteristics factors on the likelihood that households will have a gun at home and, if so, whether they will keep it at either of two levels of risk. We find that rates of firearm ownership vary widely by household characteristics, including the state in which they reside. Simultaneously controlling for all of these factors scarcely diminishes variation in odds for ownership. Differences in the likelihood that owners will store guns unsafely are narrower and significant for fewer factors. Having children in the home scarcely affects the propensity to possess firearms but greatly reduces the chances a domestic firearm will be stored loaded and unsecured. Our findings support a consensus on the demographics of ownership but show more and stronger predictors of storage behavior than previous work. Differing dynamics of ownership and storage reveal the existence of two regional gun cultures. From these findings, we conclude that to mitigate mortality risks associated with guns in the home, encouraging safer storage by owners may be as effective as controlling sales. States and localities should test a range of promising but largely unproven interventions.

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.

Weaker gun state laws are associated with higher rates of suicide secondary to firearms

BACKGROUND

Firearm-related suicides comprise over two-thirds of gun-related violence in the United States, and gun laws and policies remain under scrutiny, with many advocating for revision of the regulatory map for lawful gun ownership, aiming at restricting access and distribution of these weapons. However, the quantitative relationship between how strict gun laws are and the incidence of firearm violence with their associated mortality is largely unknown. We therefore, sought to explore the impact of firearm law patterns among states on the incidence and outcomes of firearm-related suicide attempts, utilizing established objective criteria.

METHODS

The National Inpatient Sample for the years 1998-2011 was queried for all firearm-related suicides. Discharge facilities were stratified into five categories (A, B, C, D, and F, with A representing states with the most strict and F representing states with the least strict laws) based on the Brady Campaign to prevent Gun Violence that assigns scorecards for every state. The primary outcomes were suicide attempts and in-hospital mortality per 100,000 populations by Brady state grade.

RESULTS

During the 14-year study period, 34,994 subjects met inclusion criteria. The mean age was 42.0 years and 80.1% were male. A handgun was utilized by 51.8% of patients. The overall mortality was 33.3%. Overall, 22.0% had reported psychoses and 19.3% reported depression. After adjusting for confounding factors and using group A as reference, there were higher adjusted odds for suicide attempts for patients admitted in group C, D, and F category states (1.73, 2.09, and 1.65, respectively, all P < 0.001).

CONCLUSIONS

Firearm-related suicide attempt injuries are more common in states with less strict gun laws, and these injuries tend to be associated with a higher mortality. Efforts aimed at nationwide standardization of firearm state laws are warranted, particularly for young adults and suicide-prone populations.

LEVEL OF EVIDENCE

III.

STUDY TYPE

Trauma Outcomes study.