The association between changes in household firearm ownership and rates of suicide in the United States, 1981-2002

Geographic Variation, Economic Activity, and Labor Market Characteristics in Trajectories of Suicide in the United States, 2008-2020

Suicide rates in the United States have increased over the past 15 years, with substantial geographic variation in these increases; yet there have been few attempts to cluster counties by the magnitude of suicide rate changes according to intercept and slope or to identify the economic precursors of increases. We used vital statistics data and growth mixture models to identify clusters of counties by their magnitude of suicide growth from 2008 to 2020 and examined associations with county economic and labor indices. Our models identified 5 clusters, each differentiated by intercept and slope magnitude, with the highest-rate cluster (4% of counties) being observed mainly in sparsely populated areas in the West and Alaska, starting the time series at 25.4 suicides per 100,000 population, and exhibiting the steepest increase in slope (0.69/100,000/year). There was no cluster for which the suicide rate was stable or declining. Counties in the highest-rate cluster were more likely to have agricultural and service economies and less likely to have urban professional economies. Given the increased burden of suicide, with no clusters of counties improving over time, additional policy and prevention efforts are needed, particularly targeted at rural areas in the West.

Violent Experiences and Patterns of Firearm Ownership From Childhood to Young Adulthood

Importance

Young adults in their 20s are at high relative risk for self- and other-directed firearm injury, but little is known about gun access patterns for this group.

Objective

To describe the longitudinal patterns of firearm access from childhood to young adulthood and to estimate whether violence experienced as a child or as an adult is associated with gun ownership in young adulthood.

Design, Setting, and Participants

The Great Smoky Mountains Study included participants from 11 contiguous, mostly rural counties in the Southeastern US. The first wave was completed in 1993 and the most recent in 2019. Periodic survey data were gathered in adolescence through participants' late 20s. In 2023, adjusted Poisson regression with incident rate ratios (IRRs) and 95% CIs were used to estimate associations between violence and gun ownership in young adulthood in 3 age cohorts from the original sample.

Exposures

Violent experiences in childhood (bullying, sexual and physical abuse, violent events, witnessing trauma, physical violence between parents, and school/neighborhood dangerousness) or adulthood (physical and sexual assault).

Main Outcomes and Measures

Initiating gun ownership was defined as no gun access or ownership in childhood followed by gun ownership at age 25 or 30 years. Maintaining gun ownership was defined as reporting gun access or ownership in at least 1 survey in childhood and ownership at age 25 or 30 years.

Results

Among 1260 participants (679 [54%] male; ages 9, 11, and 13 years), gun access or ownership was more common in childhood (women: 366 [63%]; men: 517 [76%]) than in adulthood (women: 207 [36%]; men: 370 [54%]). The most common longitudinal pattern was consistent access or ownership from childhood to adulthood (373 [35%]) followed by having access or ownership in childhood only (408 [32%]). Most of the violent exposures evaluated were not significantly associated with the outcomes. Being bullied at school was common and was associated with reduced ownership initiation (IRR, 0.76; 95% CI, 0.61-0.94). Witnessing a violent event was significantly associated with increased probability of becoming a gun owner in adulthood (IRR, 1.24; 95% CI, 1.03-1.49).

Conclusions and Relevance

In this cohort study, gun ownership and access were transitory, even in a geographic area where gun culture is strong. Early adulthood-when the prevalence of gun ownership was relatively low-may represent an opportune time for clinicians and communities to provide education on the risks associated with firearm access, as well as strategies for risk mitigation.

Suicide versus homicide firearm injury patterns on trauma systems in a study of the National Trauma Data Bank (NTDB)

Firearm related mortality in the USA surpassed all other developed countries. This study hypothesizes that injury patterns, weapon type, and mortality differ between suicide groups as opposed to homicide. The American College of Surgeons National Trauma Database was queried from January 2017 to December 2019. All firearm related injuries were included, and weapon type was abstracted. Differences between homicide and suicide groups by sex, age, race, and injury severity were compared using a Mann–Whitney test for numerical data and Fisher’s exact test for categorical data. The association between weapon type and mortality relative to suicide as opposed to homicide was assessed in Fisher’s exact tests. Significance was defined as p < 0.05. There were 100,031 homicide and 11,714 suicide subjects that met inclusion criteria. Homicides were mostly assault victims (97.6%), male (88%), African–American (62%), had less severe injury (mean (ISS) 12.07) and a median age of 20 years old (IQR: 14, 30, p < 0.01). Suicides were mostly male (83%), white (79%), had more severe injury (mean ISS 20.73), and a median age of 36 years old (IQR: 19, 54, p < 0.01). Suicide group had higher odds of head/neck (OR = 13.6) or face (OR = 5.7) injuries, with lower odds of injury to chest (OR = 0.55), abdominal or pelvic contents (OR = 0.25), extremities or pelvic girdle (OR = 0.15), or superficial soft tissue (OR = 0.32). Mortality rate was higher for suicide group (44.8%; 95% confidence interval (CI) 43.9%, 45.7%) compared to the homicide group (11.5%; 95% CI 11.3%, 11.7%). Suicide had higher mortality, more severe injuries, and more head/neck/facial injuries than homicide. Majority of suicides were with handguns.

Prevalence and Correlates of Firearm Access Among Post-9/11 US Women Veterans Using Reproductive Healthcare: a Cross-Sectional Survey

BACKGROUND

Suicide rates have increased among women Veterans, with increased use of firearms as the method. Addressing suicide risk in this population requires understanding the prevalence and correlates of firearm access in healthcare settings frequented by women Veterans.

OBJECTIVES

Characterize the prevalence and correlates of firearm ownership and storage practices among women Veterans using Department of Veterans Affairs (VA) reproductive healthcare (RHC) services.

DESIGN

Cross-sectional national survey conducted in 2018-2019 (17.9% response rate).

PARTICIPANTS

Post-9/11 women Veterans using RHC (n=350).

MAIN MEASURES

VA Military Sexual Trauma Screen, PTSD Checklist for DSM-5, Hurt/Insult/Threaten/Scream, Columbia-Suicide Severity Rating Scale screener, self-reported firearm access.

KEY RESULTS

38.0% (95% confidence interval [95% CI]: 32.9, 43.3) of participants reported personally owning firearms, and 38.9% (95% CI: 33.7, 44.2) reported other household members owned firearms. Among those with firearms in or around their homes, 17.8% (95% CI: 12.3, 24.4) and 21.9% (95% CI: 15.9, 28.9) reported all were unsafely stored (loaded or unlocked, respectively). Women who experienced recent intimate partner violence were less likely to report personally owning firearms (adjusted prevalence ratio [APR]=0.75; 95% CI: 0.57, 0.996). Those who experienced military sexual harassment (APR=1.46; 95% CI=1.09, 1.96), were married (APR=1.74; 95% CI: 1.33, 2.27), or lived with other adult(s) (APR=6.26; 95% CI: 2.87, 13.63) were more likely to report having household firearms owned by someone else. Storing firearms loaded was more prevalent among women with lifetime (APR=1.47; 95% CI=1.03, 2.08) or past-month (APR=1.69; 95% CI=1.15, 2.48) suicidal ideation and less likely among those with other adult(s) in the home (unadjusted PR=0.62; 95% CI=0.43, 0.91). Those with parenting responsibilities (APR=0.61; 95% CI=0.38, 0.97) were less likely to store firearms unlocked.

CONCLUSIONS

Firearm access is prevalent among post-9/11 women Veterans using VA RHC. Interpersonal factors may be important determinants of firearm access in this population. Safe firearm storage initiatives are needed among women Veterans using RHC, particularly for those with suicidal ideation.

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.

Quo vadis? Problems of prevention of suicidal behavior in adolescents (narrative review)

Among the existing problems related to the health and quality of life of Russian youth, the topic of suicidal behavior is the most biased, but at the same time the least solvable in a practical sense. This is due to the fact that suicide is an integrative phenomenon, and the suicidal act itself is interpreted in essence as the tip of the iceberg. Especially clearly manifested in adolescence is the fact that suicidal readiness is associated not so much with the level of severity of mental pathology and personality dysfunction, but with the general social context of total trouble. In this regard, suicide prevention cannot be based only on the timely identification of persons at risk for mental pathology. The purpose of this article is to provide a meaningful overview of modern integrated prevention programs that have shown to be effective in reducing the level of suicidal behavior among young people, compared with isolated approaches. The article discusses the problems associated with the implementation and evaluation of the effectiveness of such preventive programs, and also suggests approaches that allow them to be adapted in the public health system and, in particular, in the clinical practice of psychiatrists.

The Recent Rise of Suicide Mortality in the United States

Suicide is a major public health concern in the United States. Between 2000 and 2018, US suicide rates increased by 35%, contributing to the stagnation and subsequent decrease in US life expectancy. During 2019, suicide declined modestly, mostly owing to slight reductions in suicides among Whites. Suicide rates, however, continued to increase or remained stable among all other racial/ethnic groups, and little is known about recent suicide trends among other vulnerable groups. This article (a) summarizes US suicide mortality trends over the twentieth and early twenty-first centuries, (b) reviews potential group-level causes of increased suicide risk among subpopulations characterized by markers of vulnerability to suicide, and (c) advocates for combining recent advances in population-based suicide prevention with a socially conscious perspective that captures the social, economic, and political contexts in which suicide risk unfolds over the life course of vulnerable individuals.

Prevalence of Firearm Ownership Among Individuals With Major Depressive Symptoms

IMPORTANCE

Both major depression and firearm ownership are associated with an increased risk for death by suicide in the United States, but the extent of overlap among these major risk factors is not well characterized.

OBJECTIVE

To assess the prevalence of current and planned firearm ownership among individuals with depression.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional survey study using data pooled from 2 waves of a 50-state nonprobability internet survey conducted between May and July 7, 2021. Internet survey respondents were 18 years of age or older and were sampled from all 50 US states and the District of Columbia.

MAIN OUTCOMES AND MEASURES

Self-reported firearm ownership; depressive symptoms as measured by the 9-item Patient Health Questionnaire.

RESULTS

Of 24 770 survey respondents (64.6% women and 35.4% men; 5.0% Asian, 10.8% Black, 7.5% Hispanic, and 74.0% White; mean [SD] age 45.8 [17.5]), 6929 (28.0%) reported moderate or greater depressive symptoms; this group had mean (SD) age of 38.18 (15.19) years, 4587 were female (66.2%), and 406 were Asian (5.9%), 725 were Black (10.5%), 652 were Hispanic (6.8%), and 4902 were White (70.7%). Of those with depression, 31.3% reported firearm ownership (n = 2167), of whom 35.9% (n = 777) reported purchasing a firearm within the past year. In regression models, the presence of moderate or greater depressive symptoms was not significantly associated with firearm ownership (adjusted odds ratio [OR], 1.07; 95% CI, 0.98-1.17) but was associated with greater likelihood of a first-time firearm purchase during the COVID-19 pandemic (adjusted OR, 1.77; 95% CI, 1.56-2.02) and greater likelihood of considering a future firearm purchase (adjusted OR, 1.53; 95% CI, 1.23-1.90).

CONCLUSIONS AND RELEVANCE

In this study, current and planned firearm ownership was common among individuals with major depressive symptoms, suggesting a public health opportunity to address this conjunction of suicide risk factors.

State firearm laws, gun ownership, and K-12 school shootings: Implications for school safety

Limited research has been conducted on the state-level factors that may be associated with intentional school shootings. We obtained school shooting data from the Washington Post that identified any act of intentional interpersonal gunfire in a K-12 school over the course of two decades. We also compiled new data on active school shootings during the same twenty-year time period, which identified any attempted mass shooting incident in a K-12 school. We conducted a time-series analysis to measure the association of permissiveness of state firearm laws and state gun ownership with K-12 school shootings and active shootings. More permissive firearm laws and higher rates of gun ownership were associated with higher rates of both school shootings and active school shootings after controlling for critical covariates. Specific recommendations for K-12 schools to consider as they seek to prevent acts of intentional gunfire on school grounds are presented.

Role of Firearm Ownership on 2001-2016 Trends in U.S. Firearm Suicide Rates

INTRODUCTION

In the U.S., state-level household firearm ownership is strongly associated with firearm suicide mortality rates. Whether the recent increases in firearm suicide are explained by state-level household firearm ownership rates and trends remains unknown.

METHODS

Mortality data from the U.S. National Vital Statistics System and an estimate of state-level household firearm ownership rate were used to conduct hierarchical age-period-cohort (random-effects) modeling of firearm suicide mortality between 2001 and 2016. Models were adjusted for individual-level race and sex and for state-level poverty rate, unemployment rate, median household income in U.S. dollars, population density, and elevation.

RESULTS

Between 2001 and 2016, the crude national firearm suicide mortality rate increased from 6.8 to 8.0 per 100,000, and household firearm ownership rate remained relatively stable, at around 40%. Both variables were markedly heterogeneous and correlated at the state level. Age-period-cohort models revealed period effects (affecting people across ages) and cohort effects (affecting specific birth cohorts) underlying the recent increases in firearm suicide. Individuals born after 2000 had higher firearm suicide rates than most cohorts born before. A 2001-2006 decreasing period effect was followed, after 2009, by an increasing period effect that peaked in 2015. State-level household firearm ownership rates and trends did not explain cohort effects and only minimally explained period effects.

CONCLUSIONS

State-level firearm ownership rates largely explain the state-level differences in firearm suicide but only marginally explain recent increases in firearm suicide. Although firearms in the home increase firearm suicide risk, the recent national rise in firearm suicide might be the result of broader, more distal causes of suicide risk.

Firearm ownership and access to healthcare in the U.S.: A cross-sectional analysis of six states

Provider-led firearm storage counseling is a form of firearm suicide prevention intervention. Little research examines whether barriers to healthcare access for at-risk individuals limit this intervention's impact. This study explores the relationship between household firearm presence/storage practices and healthcare access/utilization using a cross-sectional analysis of the 2017 Behavioral Risk Factor Surveillance System (BRFSS), which included state-representative data from six states that completed the Firearm Safety and Healthcare Access Modules: California, Idaho, Kansas, Oregon, Texas, and Utah. Exposures were household firearm presence and firearm storage practices. Outcomes were lacking health insurance, not having a healthcare provider, inability to afford care, and no recent routine checkup. Logistic regression models adjusted for age, sex, education, employment, children in the household, and state of residency. Our analysis included 31,888 individuals; 31.1% reported a household firearm. Compared to those in firearm-owning households, those in non-firearm-owning households had higher odds of being uninsured (aOR 1.99, 95%CI 1.60-2.48), not having a provider (aOR 1.40, 95%CI 1.18-1.67), and reporting cost as a barrier to care (aOR 1.37, 95%CI 1.13-1.67). Among firearm-owning households, those with firearms stored loaded and unlocked had higher odds of lacking a personal healthcare provider (aOR 1.52, 95%CI 1.07-2.15) compared to individuals in homes where firearms were stored unloaded. Results indicate that while individuals in firearm-owning households are more likely than non-firearm owning households to have healthcare access, those in homes with the riskiest firearm storage practices had less access. Provider-led counseling may have limited reach for individuals in homes with risky firearm storage practices.

Alcohol and drug offenses and suicide risk among men who purchased a handgun in California: A cohort study

Firearm access is a risk factor for firearm suicide; substance use may confer additional risk. In this retrospective cohort study, we estimated the associations between prior alcohol and drug charges at the time of handgun purchase and subsequent suicide among men in California. The sample comprised all men who legally purchased a handgun in California in 2001 and who were age ≥ 21 at the time of acquisition (N = 101,377), identified in the California Department of Justice (CA DOJ) Dealer's Record of Sale database. Exposures included alcohol and drug criminal charges and convictions accrued January 1, 1990 until the first ('index') handgun acquisition in 2001, recorded in the CA DOJ Criminal History Information System. Outcomes included suicide and firearm suicide occurring after the index purchase and before January 1, 2016. A total of 1907 purchasers had alcohol charges, 1248 had drug charges, and 304 had both; 594 purchasers died by suicide (516 by firearm suicide). Compared with those with neither alcohol nor drug charges, those with alcohol charges had 2.20 times the hazard of suicide (95% confidence interval [CI], 1.39-3.46) and 2.22 times the hazard of firearm suicide (95% CI, 1.36-3.62). Risk was most elevated among those with more recent charges and those with 2 or more charges, and in the time period closest to the purchase. The associations for drug charges and the combination of alcohol and drug charges were not distinguishable from the null. Firearm owners with alcohol offenses may benefit from intervention to reduce firearm access and alcohol use.

Rural youth's exposure to firearm violence and their attitudes regarding firearm safety measures

BACKGROUND

In the wake of an epidemic in firearm-related deaths and injuries, youth have become leading voices of concern. This study's objective was to investigate rural youth's personal experiences with firearm-related violence, and their attitudes towards firearms and gun violence prevention strategies.

METHODS

Attendees of the 2019 Iowa FFA Leadership Conference were surveyed about personal experiences with firearm-associated deaths and injuries, and their attitudes regarding firearm-related issues. Descriptive (frequencies), bivariate (chi square, Fisher's exact test) and multivariable logistic regression analyses were performed utilizing Stata 15.1 (StataCorp, College Station, Texas).

RESULTS

Responses from 1382 FFA members 13-18 years of age were analyzed. About 5% had personally seen someone threatened with a firearm. Over one-third (36%) stated they knew someone who had been killed or injured by gunfire. Of these, over two-thirds knew of someone who had died or was injured unintentionally and 30% knew of someone killed or injured intentionally (e.g. suicide). Nearly all agreed or strongly agreed that the right to use firearms for hunting and shooting sports should be legal (94%), that a firearm safety course should be required to get a hunting license (89%), and that there should be a required background check before purchasing a firearm (89%). Over three-fifths (61%) agreed or strongly agreed that there should be laws requiring safe storage of firearms in homes. Although still high, lesser support for firearm safety policies was seen among males, older youth, participants living on farms or in the country, and youth who hunted, had firearms in their homes, and/or were in homes with unsafe firearm storage.

CONCLUSIONS

The majority of youth in this study supported firearm safety measures including required training, background checks, and safe firearm storage in homes. These findings are consistent with the national youth-led call for firearm safety. Additionally, over one-third of respondents personally knew someone who was killed or injured by a firearm and 5% had seen someone or been personally threatened with firearm violence. Our study did not investigate the effects of firearm violence on participants' mental health and wellbeing, but future studies addressing this question seem highly justified.

Suicide prevention in childhood and adolescence: a narrative review of current knowledge on risk and protective factors and effectiveness of interventions

INTRODUCTION

Suicide is a global mental health problem for people of all ages. While rates of suicide in children and adolescents are reported as lower than those in older populations worldwide, they represent the third leading cause of death in 15-19-year-olds. The rates are higher among boys than girls worldwide, though the death rates for girls exceed those for boys in Bangladesh, China, India, and Nepal. There has been a general decrease in adolescent suicide rates over recent decades. However, increases are reported in South East Asia as well as South America over the same time period.

METHODS

A narrative review method has been used to summarize current knowledge about risk and protective factors for suicide among children and adolescents and to discuss evidence-based strategy for suicide prevention in this age group.

RESULTS

Identified suicide risk and protective factors for children and adolescents largely overlap with those for adults. Nevertheless, developmental characteristics may strengthen the impact of some factors, such as decision-making style, coping strategies, family and peer relationships, and victimization. The implementation of evidence-based suicide preventive strategies is needed. Restricting access to lethal means, school-based awareness and skill training programs, and interventions delivered in clinical and community settings have been proven effective. The effectiveness of gatekeeper training and screening programs in reducing suicidal ideation and behavior is unproven but widely examined in selected settings.

DISCUSSION

Since most studies have been conducted in western countries, future research should assess the effectiveness of these promising strategies in different cultural contexts. The use of more rigorous study designs, the use of both short- and long-term follow-up evaluations, the larger inclusion of individuals belonging to vulnerable groups, the evaluation of online intervention, and the analysis of programs' cost-effectiveness are also required.

Adolescent Suicide, Household Firearm Ownership, and the Effects of Child Access Prevention Laws

OBJECTIVE

This study has 3 objectives: to examine the association between state-level firearm ownership and suicide among adolescents of high school age; to compare the strength of the firearm ownership-suicide association among adolescents relative to adults; and to evaluate the relationship between 11 child access prevention (CAP) laws and suicide.

METHOD

Using an ecological time series cross-sectional design, we modeled suicide rates from January 1, 1991, to December 31, 2017, as a function of household firearm ownership and states' implementation of CAP provisions using fixed effect negative binomial models.

RESULTS

There were 37,652 suicides among adolescents between the ages of 14 and 18 years during the study period, and more than half of all suicides (51.5%, n = 19,402) involved firearms. Each 10 percentage-point increase in states' firearm ownership was associated with a 39.3% (35.1%-43.5%) increase in firearm suicide, which in turn contributed a 6.8% (2.5%-11.1%) increase in all-cause suicide. The association between firearm ownership and suicide was approximately 2 times stronger among adolescents relative to adults. Policies mandating locks and safe storage were associated with a 13.1% (2.7%-22.3%) reduction in adolescent firearm suicide and an unexplained 8.7% (1.2%-15.7%) reduction in non-firearm suicide. CAP provisions were associated with reduced firearm suicide across the lifespan, but effects were stronger among adolescents.

CONCLUSION

There is an increased risk of adolescent suicide associated with household firearm ownership, and safe storage provisions are associated with decreased adolescent firearm suicide.

Firearm-related injuries and deaths in Ontario, Canada, 2002-2016: a population-based study

BACKGROUND

Firearm-related injury is an important and preventable cause of death and disability. We describe the burden, baseline characteristics and regional rates of firearm-related injury and death in Ontario.

METHODS

We conducted a population-based cross-sectional study using linked data from health administrative data sets held at ICES. We identified residents of Ontario of all ages who were injured or died as a result of a firearm discharge between Apr. 1, 2002, and Dec. 31, 2016. We included injuries classified as assault, unintentional, self-harm or undetermined intent secondary to handguns, rifles, shotguns and larger firearms. The primary outcome was the incidence of nonfatal and fatal injuries resulting in an emergency department visit, hospital admission or death. We also describe regional and temporal rates.

RESULTS

We identified 6483 firearm-related injuries (annualized injury rate 3.54 per 100 000 population), of which 2723 (42.3%) were fatal. Assault accounted for 40.2% (1494/3715) of nonfatal injuries and 25.5% (694/2723) of deaths. Young men, predominantly in urban neighbourhoods, within the lowest income quintile were overrepresented in this group. Injuries secondary to self-harm accounted for 68.0% (1366/2009) of injuries and occurred predominantly in older men living in rural Ontario across all income quintiles. The case fatality rate of injuries secondary to self-harm was 91.7%. Self-harm accounted for 1842 deaths (67.6%).

INTERPRETATION

We found that young urban men were most likely to be injured in firearm-related assaults and that more than two-thirds of self-harm-related injuries occurred in older rural-dwelling men, most of whom died from their injuries. This highlights a need for suicide-prevention strategies in rural areas targeted at men aged 45 or older.

Alcohol policies, firearm policies, and suicide in the United States: a lagged cross-sectional study

BACKGROUND

Alcohol and firearms are commonly involved in suicide in the United States. State alcohol and firearm policies may impact alcohol and firearm related suicide, yet little is known about these relationships. This study examines relationships between state alcohol and firearm policies and suicides involving alcohol, guns, or both, and explores interactive policy associations.

METHODS

Alcohol policies were assessed with the Alcohol Policy Scale. Firearm policies were assessed using the Gun Law Scorecard from Giffords Law Center. Suicide data from the National Violent Death Reporting System in 2015 covered 22 states. State- and individual-level GEE Poisson and logistic regression models assessed relationships between policies and firearm- and/or alcohol-involved suicides with a 1-year lag.

RESULTS

In 2015, there were 8996 suicide deaths with blood alcohol concentration test results in the 22 included states. Of those deaths, alcohol and/or firearms were involved in 5749 or 63.9%. Higher alcohol and gun law scores were associated with reduced incidence rates and odds of suicides involving either alcohol or firearms (adjusted incidence rate ratios [IRR] 0.72 (95% CI 0.63, 0.83) for alcohol policies, 0.86 (95% CI 0.82, 0.90) for firearm policies). Relationships were similar for suicides involving both alcohol and firearms, and there was an interactive effect, such that states with restrictive policies for both had the lowest rates of suicides involving alcohol or guns.

CONCLUSIONS

More restrictive alcohol and firearm policies are associated with lower rates and odds of suicides involving alcohol or firearms, and alcohol and firearms, and may be a promising means by which to reduce suicide.

State handgun purchase age minimums in the US and adolescent suicide rates: regression discontinuity and difference-in-differences analyses

OBJECTIVE

To evaluate the association between US state policies that establish age 18 or 21 years as the minimum purchaser age for the sale of handguns and adolescent suicide rate.

DESIGN

Regression discontinuity and difference-in-differences analyses.

SETTING

46 US states without policy changes between 2001 and 2017; Missouri and South Carolina, which lowered the age for handgun sales in 2007 and 2008, respectively; and West Virginia and Wyoming, which increased the age for handgun sales in 2010.

PARTICIPANTS

Adolescents aged 13 to 20 years(554 461 961 from 2001 to 2017) in the regression discontinuity analysis, and adolescents aged 18 to 20 years (168 934 041 from 2002 to 2014) in the main difference-in-differences analysis.

MAIN OUTCOME MEASURE

Suicide rate per 100 000 adolescents.

RESULTS

In the regression discontinuity analysis, state policies that limited the sale of handguns to those aged 18 or older (relative to 21 or older) were associated with an increase in suicide rate among adolescents aged 18 to 20 years equivalent to 344 additional suicides in each state where they were in place between 2001 and 2017. In the difference-in-differences analysis, state policies that limited the sale of handguns to those aged 21 or older were associated with 1.91 fewer suicides per 100 000 adolescents aged 18 to 20 years (95% confidence interval -3.13 to -0.70, permutation adjusted P=0.025). In the difference-in-differences analysis, there were 1.83 fewer firearm related suicides per 100 000 adolescents (-2.66 to -1.00, permutation adjusted P=0.002), with no association between age 21 handgun sales policies and non-firearm related suicides. Separate event study estimates indicated increases in suicide rates in states that lowered the age of handgun sales, with no association in states that increased the age of handgun sales.

CONCLUSIONS

A clear discontinuity was shown in the suicide rate by age at age 18 in states that limited the sale of handguns to individuals aged 18 or older. State policies to limit the sale of handguns to individuals aged 21 or older were associated with a reduction in suicide rates among adolescents. Increases in suicide rates were observed after states lowered the age of handgun sales, but no effect was found in states that increased the age of handgun sales.

Suicide fatalities in the US compared to Canada: Potential suicides averted with lower firearm ownership in the US

Introduction and objective

The United States (US) has the highest rate of firearm suicides in the world. The US and Canada are comparable countries with markedly different rates of firearm ownership, providing an opportunity to estimate suicide fatalities that could be averted in the US with a lower rate of firearm ownership.

Methods

We compared 2016 US suicide fatality rates–standardized within fourteen sex-specific age groups to reflect the ethnic composition of Canada–to 2016 Canadian suicide rates. We then calculated the number and proportion of suicides that could be averted in the US if the US had the same rates of suicide as in Canada.

Results

If the US had the same suicide rates as in Canada, we estimate there would be approximately 25.9% fewer US suicide fatalities, equivalent to 11,630 suicide fatalities averted each year. This decline would be driven by a 79.3% lower rate of firearm-specific suicide fatalities. The male suicide fatality rate would be 28.8% lower and equivalent to 9,992 fewer suicide fatalities each year. The female suicide fatality rate would be 16.0% lower and equivalent to 1,638 fewer suicide fatalities each year. While 36% of firearm suicide fatalities could be replaced by non-firearm suicide fatalities, 64% of firearm fatalities could be averted entirely.

Conclusions

US policymakers may wish to consider policies that would reduce rates of firearm ownership, given that that about 26% of US suicide fatalities might be averted if the US had the same suicide rates as in Canada, a country with drastically lower firearm ownership rates.

Cluster analysis of child homicide in South Korea

BACKGROUND

There has been an insufficient in-depth analysis of the nature and prevalence of the typologies of child homicide in Asia, particularly in South Korea.

OBJECTIVE

In the current study, we sought to determine the prevalence and identify the heterogeneity of the child homicide phenomenon in South Korea.

PARTICIPANT AND SETTINGS

All 341 original case files (i.e., hospital, police, and autopsy reports) of homicide incidents involving children aged 0-18 in 2016 were obtained from the forensic autopsy archives of the National Forensic Service (NFS), which handles 100 % of the medico-legal autopsies in South Korea. These were examined and reclassified based on our definition.

METHOD

A cluster analysis using Gower's distance was applied, which has rarely been utilized in this field of research. By performing a qualitative analysis, we first extracted 70 (numerical, logical, categorical) crime, victim, perpetrator, and household relevant variables, which were later utilized in the cluster analysis.

RESULTS

Among the 341 cases from 2016, 95 were judged to be at least suspicious child homicide cases. When applying the cluster analysis, eight sub-clusters were extracted: child torture, maternal filicide, neonaticide, death not related to previous abuse, paternal filicide, paternal infanticide, maternal infanticide, and psychotic killings.

CONCLUSIONS

The commonality and the unique aspect of the child homicide phenomenon in South Korea, in comparison with the results from previous research from other countries, are discussed.

Austrian firearm legislation and its effects on suicide and homicide mortality: A natural quasi-experiment amidst the global economic crisis

Background:

Restriction of access to suicide methods has been shown to effectively reduce suicide mortality rates.

Aims:

To examine how the global economic crisis of 2008 and the firearm legislation reform of 1997 affected suicide and homicide mortality rate within Austria.

Methods:

Official data for the years 1985–2016 for firearm certificates, suicide, homicide, unemployment rates and alcohol consumption were examined using auto regressive error and Poisson regression models.

Results:

Firearm certificates, total suicide mortality rate, suicide and homicides by firearms, and the fraction of firearm suicides/homicides among all suicides/homicides decreased after the firearm legislation reform in 1997. However, significant trend changes can be observed after 2008. The availability of firearm certificates significantly increased and was accompanied by significant changes in trends of firearm suicide and homicide rates. Concurrently, the total suicide mortality rate in 2008, for the first time since 1985, stopped its decreasing trend. While the total homicide rate further decreased, the fraction of firearm homicides among all homicides significantly increased.

Conclusion:

The initially preventative effect of the firearm legislation reform in Austria in 1997 seems to have been counteracted by the global economic downturn of 2008. Increased firearm availability was associated with corresponding increases in both firearm suicide and firearm homicide mortality. Restrictive firearm legislation should be an imperative part of a country’s suicide prevention programme. Although firearm legislation reform may have long-lasting effects, societal changes may facilitate compensatory firearm acquisitions and thus counteract preventive efforts, calling in turn again for adapted counter-measures.

Firearm Injuries and Children: Position Statement of the American Pediatric Surgical Association

Firearm injuries are the second most common cause of death in children who come to a trauma center, and pediatric surgeons provide crucial care for these patients. The American Pediatric Surgical Association (APSA) is committed to comprehensive pediatric trauma readiness, including firearm injury prevention. The APSA supports a public health approach to firearm injury, and it supports availability of quality mental health services. The APSA endorses policies for universal background checks, restrictions on assault weapons and high-capacity magazines, strong child access protection laws, and a minimum purchase age of 21 years. The APSA opposes efforts to keep physicians from counseling children and families about firearms. The APSA promotes research to address this problem, including increased federal research support and research into the second victim phenomenon. The ASPA supports school safety and readiness, including bleeding control training. Although it may be daunting to try to reduce firearm deaths in children, the United States has seen success in reducing motor vehicle deaths through a multidimensional approach: prevention, design, policy, behavior, and trauma care. The ASPA believes that a similar public health approach can succeed in saving children from death and injury from firearms. The ASPA is committed to building partnerships to accomplish this.

Firearm injuries and children: Position statement of the American Pediatric Surgical Association

Firearm injuries are the second most common cause of death in children who come to a trauma center, and pediatric surgeons provide crucial care for these patients. The American Pediatric Surgical Association (APSA) is committed to comprehensive pediatric trauma readiness, including firearm injury prevention. APSA supports a public health approach to firearm injury, and it supports availability of quality mental health services. APSA endorses policies for universal background checks, restrictions on assault weapons and high capacity magazines, strong child access protection laws, and a minimum purchase age of 21 years. APSA opposes efforts to keep physicians from counseling children and families about firearms. APSA promotes research to address this problem, including increased federal research support and research into the second victim phenomenon. APSA supports school safety and readiness, including bleeding control training. While it may be daunting to try to reduce firearm deaths in children, the U.S. has seen success in reducing motor vehicle deaths through a multidimensional approach - prevention, design, policy, behavior, trauma care. APSA believes that a similar public health approach can succeed to save children from death and injury from firearms. APSA is committed to building partnerships to accomplish this. TYPE OF STUDY: APSA Position Statement. LEVEL OF EVIDENCE: Level V, Expert Opinion.

State gun laws, gun ownership, and mass shootings in the US: cross sectional time series

OBJECTIVE

To determine whether restrictiveness-permissiveness of state gun laws or gun ownership are associated with mass shootings in the US.

DESIGN

Cross sectional time series.

SETTING AND POPULATION

US gun owners from 1998-2015.

EXPOSURE

An annual rating between 0 (completely restrictive) and 100 (completely permissive) for the gun laws of all 50 states taken from a reference guide for gun owners traveling between states from 1998 to 2015. Gun ownership was estimated annually as the percentage of suicides committed with firearms in each state.

MAIN OUTCOME MEASURE

Mass shootings were defined as independent events in which four or more people were killed by a firearm. Data from the Federal Bureau of Investigation's Uniform Crime Reporting System from 1998-2015 were used to calculate annual rates of mass shootings in each state. Mass shooting events and rates were further separated into those where the victims were immediate family members or partners (domestic) and those where the victims had other relationships with the perpetrator (non-domestic).

RESULTS

Fully adjusted regression analyses showed that a 10 unit increase in state gun law permissiveness was associated with a significant 11.5% (95% confidence interval 4.2% to 19.3%, P=0.002) higher rate of mass shootings. A 10% increase in state gun ownership was associated with a significant 35.1% (12.7% to 62.7%, P=0.001) higher rate of mass shootings. Partially adjusted regression analyses produced similar results, as did analyses restricted to domestic and non-domestic mass shootings.

CONCLUSIONS

States with more permissive gun laws and greater gun ownership had higher rates of mass shootings, and a growing divide appears to be emerging between restrictive and permissive states.

What Are We Aiming For? Comparing Suicide by Firearm in Toronto With the Five Largest Metropolitan Areas in the United States

Background: US suicide rates correlate with firearm availability. Little is known about variability in rates across countries. Aims: To observe the relationship between firearm/overall suicide rates in Toronto, Canada, and the five most populous US metropolitan areas. Method: Centers for Disease Control suicide rates by age and sex for New York, Los Angeles, Chicago, Dallas-Fort Worth, and Houston metropolitan areas were compared with equivalent data for Toronto (1999-2015). Results: Suicide rates by firearm, per 100,000 population, ranged from 0.45 in Toronto to 6.03 in Houston while rates by other methods ranged from 4.34 in Dallas-Fort Worth to 7.11 in Toronto. Overall rates of suicide ranged from 6.14 in New York to 10.45 in Houston. The two cities with the highest firearm suicide rates, Dallas-Fort Worth and Houston, also had much higher overall rates. Firearm suicides were most common in men over the age of 65 in all cities. Limitations: This study could not account for cultural differences between cities/countries. Conclusion: Much higher overall rates of suicide observed for Dallas-Fort Worth and Houston appear to be associated with high rates of suicide by firearm. Advocacy for means safety should target cities with high rates of firearm suicide and, in particular, elderly men.

Household Gun Ownership and Youth Suicide Rates at the State Level, 2005-2015

INTRODUCTION

Determining whether the prevalence of gun ownership is associated with youth suicide is critical to inform policy to address this problem. The objective of this study is to investigate the relationship between the prevalence of household gun ownership in a state and that state's rate of youth suicide.

METHODS

This study, conducted in 2018, involved a secondary analysis of state-level data for the U.S. using multivariable linear regression. The relationship between the prevalence of household gun ownership and youth (aged 10-19 years) suicide rates was examined in a time-lagged analysis of state-level household gun ownership in 2004 and youth suicide rates in the subsequent decade (2005-2015), while controlling for the prevalence of youth suicide attempts and other risk factors.

RESULTS

Household gun ownership was positively associated with the overall youth suicide rate. For each 10 percentage-point increase in household gun ownership, the youth suicide rate increased by 26.9% (95% CI=14.0%, 39.8%).

CONCLUSIONS

Because states with high levels of household gun ownership are likely to experience higher youth suicide rates, these states should be especially concerned about implementing programs and policies to ameliorate this risk.

Impact of licensed federal firearm suppliers on firearm-related mortality

BACKGROUND

Legal firearm sales occur largely through suppliers that have Federal Firearm Licensees (FFLs). Since FFL density might reflect ease-of-access to firearm purchases, we hypothesized that the number of FFL dealers would be associated with firearm-related deaths. We further hypothesized that licensee-type subsets would be associated with differential risks for gun-related deaths.

METHODS

We used data from the National Center for Health Statistics National Vital Statistics System (2008-2014) and national data on Federal Firearms Licensees for 2014. Correlation analysis and linear regression analysis were performed to determine the relationship between different licensee types and firearm-related deaths. We controlled for population, number of statewide registered firearms, and the density of other types of FFLs.

RESULTS

We identified a total of 65,297 FFLs. There was a moderate correlation (R = 0.53, ρ = 0.48) between total FFL density and firearm-related death rates. Further analysis by type of firearm-related death showed a strong correlation (R = 0.81, ρ = 0.76) between total FFL density and firearm-related suicide rates. No correlation was found between total FFL density and firearm-related homicide rate. Among individual FFL types, FFL02 (firearm dealing pawnshop) density was the only FFL-type found to be correlated with firearm-related death rates. We found a strong correlation between FFL02 density and overall firearm-related death rate (R = 0.69, ρ = 0.78) and firearm-related suicide rate (R = 0.72, ρ = 0.78). Linear regression analysis showed that even while controlling for number of registered firearms and population, the number of firearm-dealing pawnshops remained significantly associated with overall firearm-related deaths and firearm-related suicides.

CONCLUSION

Access to legally distributed firearms is associated with firearm-related death rates, particularly firearm-related suicides. Specifically, firearm-dealing pawnshops were associated with suicide-related deaths. These findings suggest that deeper exploration of legal firearm access and firearm-related injuries would benefit discussion of preventative measures.

LEVEL OF EVIDENCE

Therapeutic, Level V.

Gun prevalence and suicide

In light of the ongoing debate over tighter firearm regulations, this paper considers the relationship between gun prevalence and suicide. I exploit a reform in Switzerland that reduced the prevalence of military-issued guns in private households. In Switzerland, military service is compulsory for men, and military-issued guns account for nearly half of the total number of firearms available. The results show that the firearm suicide rate decreases by 9% for a reduction in gun prevalence of 1000 guns per 100,000 inhabitants. The elasticity of gun suicides with respect to firearm prevalence is +0.48, but converges towards zero for low levels of gun prevalence. The overall suicide rate is negatively and significantly related to firearm prevalence, which indicates that non-gun methods of suicide are not perfect replacements for firearms.

State Firearm Laws and Interstate Firearm Deaths From Homicide and Suicide in the United States: A Cross-sectional Analysis of Data by County

IMPORTANCE

Firearm laws in one state may be associated with increased firearm death rates from homicide and suicide in neighboring states.

OBJECTIVE

To determine whether counties located closer to states with lenient firearm policies have higher firearm death rates.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of firearm death rates by county for January 2010 to December 2014 examined data from the US Centers for Disease Control and Prevention for firearm suicide and homicide decedents for 3108 counties in the 48 contiguous states of the United States.

EXPOSURES

Each county was assigned 2 scores, a state policy score (range, 0-12) based on the strength of its state firearm laws, and an interstate policy score (range, -1.33 to 8.31) based on the sum of population-weighted and distance-decayed policy scores for all other states. Counties were divided into those with low, medium, and high home state and interstate policy scores.

MAIN OUTCOMES AND MEASURES

County-level rates of firearm, nonfirearm, and total homicide and suicide. With multilevel Bayesian spatial Poisson models, we generated incidence rate ratios (IRR) comparing incidence rates between each group of counties and the reference group, counties with high home state and high interstate policy scores.

RESULTS

Stronger firearm laws in a state were associated with lower firearm suicide rates and lower overall suicide rates regardless of the strength of the other states' laws. Counties with low state scores had the highest rates of firearm suicide. Rates were similar across levels of interstate policy score (low: IRR, 1.34; 95% credible interval [CI], 1.11-1.65; medium: IRR, 1.36, (95% CI, 1.15-1.65; and high: IRR, 1.43; 95% CI, 1.20-1.73). Counties with low state and low or medium interstate policy scores had the highest rates of firearm homicide. Counties with low home state and interstate scores had higher firearm homicide rates (IRR, 1.38; 95% CI, 1.02-1.88) and overall homicide rates (IRR, 1.32; 95% CI, 1.03-1.67). Counties in states with low firearm policy scores had lower rates of firearm homicide only if the interstate firearm policy score was high.

CONCLUSIONS AND RELEVANCE

Strong state firearm policies were associated with lower suicide rates regardless of other states' laws. Strong policies were associated with lower homicide rates, and strong interstate policies were also associated with lower homicide rates, where home state policies were permissive. Strengthening state firearm policies may prevent firearm suicide and homicide, with benefits that may extend beyond state lines.

A BAYESIAN SPATIAL AND TEMPORAL MODELING APPROACH TO MAPPING GEOGRAPHIC VARIATION IN MORTALITY RATES FOR SUBNATIONAL AREAS WITH R-INLA

Hierarchical Bayes models have been used in disease mapping to examine small scale geographic variation. State level geographic variation for less common causes of mortality outcomes have been reported however county level variation is rarely examined. Due to concerns about statistical reliability and confidentiality, county-level mortality rates based on fewer than 20 deaths are suppressed based on Division of Vital Statistics, National Center for Health Statistics (NCHS) statistical reliability criteria, precluding an examination of spatio-temporal variation in less common causes of mortality outcomes such as suicide rates (SRs) at the county level using direct estimates. Existing Bayesian spatio-temporal modeling strategies can be applied via Integrated Nested Laplace Approximation (INLA) in R to a large number of rare causes of mortality outcomes to enable examination of spatio-temporal variations on smaller geographic scales such as counties. This method allows examination of spatiotemporal variation across the entire U.S., even where the data are sparse. We used mortality data from 2005-2015 to explore spatiotemporal variation in SRs, as one particular application of the Bayesian spatio-temporal modeling strategy in R-INLA to predict year and county-specific SRs. Specifically, hierarchical Bayesian spatio-temporal models were implemented with spatially structured and unstructured random effects, correlated time effects, time varying confounders and space-time interaction terms in the software R-INLA, borrowing strength across both counties and years to produce smoothed county level SRs. Model-based estimates of SRs were mapped to explore geographic variation.

A BAYESIAN SPATIAL AND TEMPORAL MODELING APPROACH TO MAPPING GEOGRAPHIC VARIATION IN MORTALITY RATES FOR SUBNATIONAL AREAS WITH R-INLA

Hierarchical Bayes models have been used in disease mapping to examine small scale geographic variation. State level geographic variation for less common causes of mortality outcomes have been reported however county level variation is rarely examined. Due to concerns about statistical reliability and confidentiality, county-level mortality rates based on fewer than 20 deaths are suppressed based on Division of Vital Statistics, National Center for Health Statistics (NCHS) statistical reliability criteria, precluding an examination of spatio-temporal variation in less common causes of mortality outcomes such as suicide rates (SRs) at the county level using direct estimates. Existing Bayesian spatio-temporal modeling strategies can be applied via Integrated Nested Laplace Approximation (INLA) in R to a large number of rare causes of mortality outcomes to enable examination of spatio-temporal variations on smaller geographic scales such as counties. This method allows examination of spatiotemporal variation across the entire U.S., even where the data are sparse. We used mortality data from 2005-2015 to explore spatiotemporal variation in SRs, as one particular application of the Bayesian spatio-temporal modeling strategy in R-INLA to predict year and county-specific SRs. Specifically, hierarchical Bayesian spatio-temporal models were implemented with spatially structured and unstructured random effects, correlated time effects, time varying confounders and space-time interaction terms in the software R-INLA, borrowing strength across both counties and years to produce smoothed county level SRs. Model-based estimates of SRs were mapped to explore geographic variation.

Firearm ownership among American veterans: findings from the 2015 National Firearm Survey

BACKGROUND

While the majority of veteran suicides involve firearms, no contemporary data describing firearm ownership among US veterans are available. This study uses survey data to describe the prevalence of firearm ownership among a nationally representative sample of veterans, as well as veterans' reasons for firearm ownership.

METHODS

A cross-sectional, nationally representative web-based survey conducted in 2015.

RESULTS

Nearly half of all veterans own one or more firearms (44.9%, 95% CI 41.3-48.6%), with male veterans more commonly owning firearms than do female veterans (47.2%, 95% CI 43.4-51.0% versus 24.4%, 95%CI 15.6-36.1%). Most veteran firearm owners own both handguns and long guns (56.5%, 95% CI 51.1-61.8%); a majority cite protection as a primary reason for firearm ownership (63.1%, 95% CI 58.2-67.8%).

CONCLUSIONS

The current study is the first to provide detailed, nationally representative information about firearm ownership among U.S. veterans. Better understanding firearm ownership among veterans can usefully inform ongoing suicide prevention efforts aiming to facilitate lethal means safety among vulnerable veterans during at-risk periods.

Armed and Aging: Dementia and Firearms Do Not Mix !

The possibility that persons with dementia possess firearms is cause for concern, but only a limited number of research studies have been conducted on such a topic, usually in the form of case reports. Reducing the occurrence of the firearm-related violence requires effectively identifying dangerous individuals and keeping firearms out of their hands. The health care professionals, i.e. the social workers and the physicians, need to work together and to produce a suitable evaluation of patients with dementia to prevent firearm-related injuries and serious and irreparable damage to persons.

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.

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.

The Link Between Mental Illness and Firearm Violence: Implications for Social Policy and Clinical Practice

The United States has substantially higher levels of firearm violence than most other developed countries. Firearm violence is a significant and preventable public health crisis. Mental illness is a weak risk factor for violence despite popular misconceptions reflected in the media and policy. That said, mental health professionals play a critical role in assessing their patients for violence risk, counseling about firearm safety, and guiding the creation of rational and evidence-based public policy that can be effective in mitigating violence risk without unnecessarily stigmatizing people with mental illness. This article summarizes existing evidence about the interplay among mental illness, violence, and firearms, with particular attention paid to the role of active symptoms, addiction, victimization, and psychosocial risk factors. The social and legal context of firearm ownership is discussed as a preface to exploring practical, evidence-driven, and behaviorally informed policy recommendations for mitigating firearm violence risk.

Impact of Firearm Availability and Gun Regulation on State Suicide Rates

Past studies on suicide have investigated the association of firearm ownership and suicide risk in the United States. The aim of the present study was to build on previous work by examining the impact of firearm storage practices and the strictness of firearm regulation on suicide rates at the state level. Data were compiled from primarily three sources. Suicide and firearm ownership information was obtained from the Centers for Disease Control and Prevention. Strictness of handgun regulation was derived from figures available at the Law Center to Prevent Violence, and controls were taken from the US Bureau of the Census. Mixed models were fitted to the data. Household firearm ownership was strongly associated with both suicide by all mechanisms, and firearm suicide. Storage practices had especially elevated consequences on suicide rates. Percent with loaded guns and gun readiness increased suicide rates, and strictness of gun regulation reduced suicide rates. Ready access to firearms can make a difference between life and death. Loaded and unlocked firearms within reach become risk factors for fatal outcomes from suicidal behavior. Future research might want to examine ways of obtaining more recent data on individual firearm ownership. This study proposes several policy recommendations for suicide prevention.

Factors Associated with Achieving Complete Mental Health among Individuals with Lifetime Suicidal Ideation

The objective of this study was to identify factors associated with complete mental health among Canadians who had ever seriously considered suicide. Data for this study were obtained from Statistics Canada's 2012 Canadian Community Health Survey-Mental Health (N = 2,844). The outcome variable examined in this study was complete mental health and was analyzed using binary logistic regression. Of the 2,844 respondents with lifetime suicidal ideation, 1,088 (38.2%) had complete mental health (i.e., had flourishing mental health, no mental illness, and no suicidal ideation in the past 12 months). Those who had a confidant were seven times more likely to have complete mental health. Other factors associated with achieving complete mental health among formerly suicidal respondents include being older, being a woman, having higher income, use of religious coping, and never previously having a mental illness. Considering the importance of these protective factors in formulating public health policies will allow for a more wide-reaching approach to suicide prevention.

Firearm Ownership and Suicide Rates Among US Men and Women, 1981-2013

OBJECTIVES

To examine the relationship between state-level firearm ownership rates and gender-specific, age-adjusted firearm and total suicide rates across all 50 US states from 1981 to 2013.

METHODS

We used panel data for all 50 states that included annual overall and gender-specific suicide and firearm suicide rates and a proxy for state-level household firearm ownership. We analyzed data by using linear regression and generalized estimating equations to account for clustering.

RESULTS

State-level firearm ownership was associated with an increase in both male and female firearm-related suicide rates and with a decrease in nonfirearm-related suicide rates. Higher gun ownership was associated with higher suicide rates by any means among male, but not among female, persons.

CONCLUSIONS

We found a strong relationship between state-level firearm ownership and firearm suicide rates among both genders, and a relationship between firearm ownership and suicides by any means among male, but not female, individuals.

POLICY IMPLICATIONS

For male persons, policies that reduce firearm ownership will likely reduce suicides by all means and by firearms. For female persons, such policies will likely reduce suicides by firearms.

Critical Violent Injury in the United States: A Review and Call to Action

OBJECTIVE

This review provides an overview of what is known about violent injury requiring critical care, including child physical abuse, homicide, youth violence, intimate partner violence, self-directed injury, firearm-related injury, and elder physical abuse.

DATA SOURCES

We searched PubMed, Scopus, Ovid Evidence-Based Medicine Reviews, and the National Guideline Clearinghouse. We also included surveillance data from the Centers for Disease Control and Prevention and National Trauma Data Bank.

STUDY SELECTION

Search criteria limited to articles in English and reports of humans, utilizing the following search terms: intentional violence, intentional harm, violence, crime victims, domestic violence, child abuse, elder abuse, geriatric abuse, nonaccidental injury, nonaccidental trauma, and intentional injury in combination with trauma centers, critical care, or emergency medicine. Additionally, we included relevant articles discovered during review of the articles identified through this search.

DATA EXTRACTION

Two hundred one abstracts were reviewed for relevance, and 168 abstracts were selected and divided into eight categories (child physical abuse, homicide, youth violence, intimate partner violence, self-directed injury, firearm-related injury, and elder physical abuse) for complete review by pairs of authors. In our final review, we included 155 articles (139 articles selected from our search strategy, 16 additional highly relevant articles, many published after we conducted our formal search).

DATA SYNTHESIS

A minority of articles (7%) provided information specific to violent injury requiring critical care. Given what is known about violent injury in general, the burden of critical violent injury is likely substantial, yet little is known about violent injury requiring critical care.

CONCLUSIONS

Significant gaps in knowledge exist and must be addressed by meaningful, sustained tracking and study of the epidemiology, clinical care, outcomes, and costs of critical violent injury. Research must aim for not only information but also action, including effective interventions to prevent and mitigate the consequences of critical violent injury.

Are We Missing Something Pertinent? A Bias Analysis of Unmeasured Confounding in the Firearm-Suicide Literature

Despite the magnitude and consistency of risk estimates in the peer-reviewed literature linking firearm availability and suicide, inferring causality has been questioned on the theoretical basis that existing studies may have failed to account for the possibility that members of households with firearms differ from members of households without firearms in important ways related to suicide risk. The current bias analysis directly addresses this concern by describing the salient characteristics that such an unmeasured confounder would need to possess in order to yield the associations between firearm availability and suicide observed in the literature when, in fact, the causal effect is null. Four US studies, published between 1992 and 2003, met our eligibility criteria. We find that any such unmeasured confounder would need to possess an untenable combination of characteristics, such as being not only 1) as potent a suicide risk factor as the psychiatric disorders most tightly linked to suicide (e.g., major depressive and substance use disorders) but also 2) an order of magnitude more imbalanced across households with versus without firearms than is any known risk factor. No such confounder has been found or even suggested. The current study strongly suggests that unmeasured confounding alone is unlikely to explain the association between firearms and suicide.

Firearm Ownership and Acquisition Among Parents With Risk Factors for Self-Harm or Other Violence

OBJECTIVE

Recent policy initiatives aiming to reduce firearm morbidity focus on mental health and illness. However, few studies have simultaneously examined mental health and behavioral predictors within families, or their longitudinal association with newly acquiring a firearm.

METHODS

Population-based, longitudinal survey of 4251 parents of fifth-grade students in 3 US metropolitan areas; 2004 to 2011. Multivariate logistic models were used to assess associations between owning or acquiring a firearm and parent mental illness and substance use.

RESULTS

Ninety-three percent of parents interviewed were women. Overall, 19.6% of families reported keeping a firearm in the home. After adjustment for confounders, history of depression (adjusted odds ratio [aOR], 1.36; 95% confidence interval [CI], 1.04-1.77), binge drinking (aOR 1.75; 95% CI, 1.14-2.68), and illicit drug use (aOR 1.75; 95% CI, 1.12-2.76) were associated with a higher likelihood of keeping a firearm in the home. After a mean of 3.1 years, 6.1% of parents who did not keep a firearm in the home at baseline acquired one by follow-up and kept it in the home (average annual likelihood = 2.1%). No risk factors for self-harm or other violence were associated with newly acquiring a gun in the home.

CONCLUSIONS

Families with risk factors for self-harm or other violence have a modestly greater probability of having a firearm in the home compared with families without risk factors, and similar probability of newly acquiring a firearm. Treatment interventions for many of these risk factors might reduce firearm-related morbidity.

Contagion in Mass Killings and School Shootings

Background

Several past studies have found that media reports of suicides and homicides appear to subsequently increase the incidence of similar events in the community, apparently due to the coverage planting the seeds of ideation in at-risk individuals to commit similar acts.

Methods

Here we explore whether or not contagion is evident in more high-profile incidents, such as school shootings and mass killings (incidents with four or more people killed). We fit a contagion model to recent data sets related to such incidents in the US, with terms that take into account the fact that a school shooting or mass murder may temporarily increase the probability of a similar event in the immediate future, by assuming an exponential decay in contagiousness after an event.

Conclusions

We find significant evidence that mass killings involving firearms are incented by similar events in the immediate past. On average, this temporary increase in probability lasts 13 days, and each incident incites at least 0.30 new incidents (p = 0.0015). We also find significant evidence of contagion in school shootings, for which an incident is contagious for an average of 13 days, and incites an average of at least 0.22 new incidents (p = 0.0001). All p-values are assessed based on a likelihood ratio test comparing the likelihood of a contagion model to that of a null model with no contagion. On average, mass killings involving firearms occur approximately every two weeks in the US, while school shootings occur on average monthly. We find that state prevalence of firearm ownership is significantly associated with the state incidence of mass killings with firearms, school shootings, and mass shootings.

CAEP Position Statement on Gun Control

Firearm-related injury and death continue to be a significant problem in Canada. Since the 1990s Canadian emergency physicians (EPs) have played an active role in advocating for gun control. This paper updates the Canadian Association of Emergency Physician's (CAEP's) position on gun control. Despite a media focus on homicide, the majority of firearm-related deaths are a result of suicide. Less than 40% of firearm-related injuries are intentionally inflicted by another person. Since the implementation of Canada's gun registry in 1995, there has been a significant reduction in firearm-related suicides and intimate partner homicides. Proposed weakening of gun laws in Canada will have a significant impact on firearm-related mortality and injury. There must be instead an expansion of programs focused on prevention of suicide, intimate partner violence and gang-related violence.

The majority of intentional or unintentional firearm-related injuries involve a violation of safe storage or handling practice. The potential for future harm because of unsafe storage or handling or through gang conflict retribution supports our position that health care facilities report gunshot wounds (GSWs). Moreover, a nationwide surveillance system is necessary to support research and to guide future public policy development and legislation.

As EPs we must advocate for injury control. All firearm injuries and deaths are preventable, and we must advocate for a multifaceted approach in order to minimize this risk to our patients.

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.