Changing times: a longitudinal analysis of international firearm suicide data

Firearm-related suicides, homicides, and homicide-suicides involving security officers in two East African Countries: a press media review

BACKGROUND

Firearm violence is a growing public health problem causing death globally. With easy accessibility to firearms, suicides, homicides, and homicide-suicides have increased among security officers, especially in developing countries affected by long-standing civil wars/political insurgencies. No study has explored firearm violence in East African countries. This study describes the press media reporting of suicides, homicides, and homicide-suicides among security officers in two East African countries (Uganda and Kenya).

METHODS

Due to the absence of suicide databases among East African countries, the present study reviewed press media reports. We utilized content analysis of suicides, homicides, and homicide-suicides reports among security forces. Relevant media reports between January-2020 and May-2023 were searched. Using ANOVA and chi-square tests, we tested for statistical differences in characteristics between victims and perpetrators.

RESULTS

Among the 56 perpetrated reports, most of them were homicides 44.64% (n = 25/56), 30.36% (n = 17/56) were homicide-suicides, and 25% (n = 14/56) were suicides. Perpetrators' age ranged from 21 to 47 years, majority being males [53/56 (94.64%)]. Victims were 58, mostly Ugandans [41/58 (73.21%)] with a mean age of 33.5 ± 8.81 years. Among the three main outcomes, statistically significant difference existed by country (χ2 = 23.88, p < 0.001), and perpetrators' age (F = 8.59, p = 0.005). There was a significant difference between perpetrators and the number of victims lost by age of victims (F = 10.37, p = 0.002). Among victims, type of security of perpetrator and citizenship of victims (χ2 = 24.18, p < 0.001) showed statistical difference with Ugandans having more victims to army officers while Kenyans to police officers. Brief incident descriptions pointed towards relationship dysfunctions, alcohol/substance abuse, intentional harm, and financial disagreements, as the potential causes. Only two perpetrators were reported to have mental health-related conditions.

CONCLUSION

This study shows that media reported firearms-related suicides, homicides, and homicide-suicides among security forces commonly involve males. Perpetrators in Uganda are mainly army officers while in Kenya the perpetrators are mostly police officers. Mental health conditions were not frequently reported among perpetrators. We recommend strengthening and enforcing gun regulation policies among security officers to curb this growing problem in these countries. Routine screening of mental health problems to enable early interventions is recommended among security officers.

Trends in suicide methods in Switzerland from 1969 to 2018: an observational study

BACKGROUND

Suicide is a serious societal and health problem. We examined changes in rates of completed suicides in Switzerland between 1969-2018 with particular regard to different methods of suicide used in different subgroups of the resident population.

METHODS

We used data of the Swiss cause of death statistics and Poisson regression models to analyse annual incidence rates and calendar time trends of specific suicide methods used in population subgroups by sex (men vs women), age (10-29, 30-64, >64 years), and nationality (Swiss vs other citizenship).

RESULTS

There were 64,996 registered suicides between 1969 and 2018. Across these 5 decades, the overall suicide rate was higher in men than in women (incidence rate ratio [IRR] 2.62, 95% confidence interval [CI] 2.58-2.67), in Swiss citizens than in foreigners (IRR 2.02; 95% CI 1.97-2.07), and in older residents (>64 years) than in the age groups 30-64 years (IRR 1.35, 95% CI 1.32-1.37) and 10-29 years (IRR 2.37, 95% CI 2.32-2.43). After peaking in the 1980s, the overall suicide rate had declined in all of these population subgroups, with flattening trends over most recent years. The most common specific methods of suicide were hanging (accounting for 26.7% of all suicides) and firearms (23.6%). The rates of the specific suicide methods were usually higher in men, in Swiss citizens and in older residents, and they had typically declined over most recent decades in the population subgroups examined. However, some methods diverged from this general pattern, at least in some population subgroups. For instance, railway suicides most recently increased in younger and in male residents whereas suicides by gas and by drowning were only at a low level after rapid declines in the last millennium.

CONCLUSIONS

Restricting access to lethal means (e.g., detoxification of domestic gas), improvements in health care and media guidelines for responsible reporting of suicides are possible explanations for the generally declining suicide rates in Switzerland. Whereas some methods (e.g., poisoning by gases or drowning) had become rare, others continue to account for many suicides every year, at least in some population subgroups (e.g., firearms in older Swiss men or railway suicides in younger and in male residents). As different methods of suicide are chosen by different people or subgroups of the population, preventive efforts should include differentiated strategies and targeted measures to further reduce suicides in Switzerland and elsewhere.

Global burden and trends of firearm violence in 204 countries/territories from 1990 to 2019

Background

Gaps remained in the updated information of the firearm violence (FV) burden from a global landscape. Understanding the global burden of FV could contribute to decision-making.

Methods

Data on the FV burden, including physical violence by firearm (PVF), self-harm by firearm (SHF), and unintentional firearm injuries (UFI), were extracted from the Global Burden of Disease 2019. The temporal trends of age-standardized rate (ASR) were estimated using estimated annual percentage change (EAPC).

Results

In 2019, PVF, SHF, and UFI reported 710.64 × 10³, 335.25 × 10³, and 2,133.88 × 10³, respectively, incident cases worldwide. Their ASR (/100,000 people-years) were 9.31, 4.05, and 28.07. During 1990-2019, the overall incident ASRs of PVF presented an increasing trend (EAPC = 0.61, 95% confidence interval [CI]: 0.48 to 0.75). Notably, pronounced increasing trends were observed in Tropical Latin America, and North Africa and Middle East. However, incident trends of SHF and UFI declined globally, with the respective EAPCs being -0.68 (95% CI: -0.83 to -0.54) and -0.98 (95% CI: -1.19 to -0.77). In 2019, the ASR of death due to PVF, SHF, and UFI were 2.23, 0.65, and 0.26, and that of DALYs were 127.56, 28.10, and 17.64, respectively. Decreasing trends in the ASRs of FV were observed in most regions and countries worldwide over the past three decades, particularly that of PVF in Estonia.

Conclusion

The FV burden was heterogeneous across regions and countries, which was deeply subjected to socioeconomic factors. The findings highlighted that specific prevention strategies and interventions were required, particularly in the high prevalent settings.

Characteristics of suicide among farmers and ranchers: Using the CDC NVDRS 2003-2018

BACKGROUND

Suicide is among the top 10 causes of premature death in the United States. This study provides details on farmer and rancher suicide decedents, including demographic information, mental health status, history of suicidal thoughts and attempts, and circumstances associated with death.

METHODS

Data for this study were obtained from the Centers for Disease Control and Prevention's National Violent Death Reporting System Restricted Access Database for the years 2003-2018. Descriptive statistics and adjusted odds ratios are presented for farm and nonfarm populations in addition to farm populations by age groups and sex.

RESULTS

This study found that almost half of the farmer suicide decedents were over 65 years old. Firearms were the most widely used method for farmers and ranchers regardless of age and sex. Young farmers and ranchers that died by suicide were more likely to have had relationship problems and older farmers and ranchers that died by suicides were more likely to have had a physical health problem. Male farmer and rancher suicide decedents were more likely to die by firearm than females, and female farmer and rancher suicide decedents were likely to have resided in a small metropolitan area, however, due to small numbers and suppression in the data, most sex comparisons were not able to be presented.

CONCLUSIONS

While no clear risk factor for suicide among farmers and ranchers emerged, results underscore the complex nature of suicide and the need for multifaceted, culturally competent interventions and campaigns that address suicide risk and prevention at the individual and community levels.

Community suicide rates and related factors within a surveillance platform in Western Kenya

BACKGROUND

Suicide is an important contributor to the burden of mental health disorders, but community-based suicide data are scarce in many low- and middle-income countries (LMIC) including Kenya. Available data on suicide underestimates the true burden due to underreporting related to stigma and legal restrictions, and under-representation of those not utilizing health facilities.

METHODS

We estimated the cumulative incidence of suicide via verbal autopsies from the Health and Demographic Surveillance System (HDSS) in Kisumu County, Kenya. We then used content analysis of open history forms among deaths coded as accidents to identify those who likely died by suicide but were not coded as suicide deaths. We finally conducted a case-control study of suicides (both verbal autopsy confirmed and likely suicides) compared to accident-caused deaths to assess factors associated with suicide in this HDSS.

RESULTS

A total of 33 out of 4306 verbal autopsies confirmed suicide as the cause of death. Content analysis of a further 228 deaths originally attributed to accidents identified 39 additional likely suicides. The best estimate of suicide-specific mortality rate was 14.7 per 100,000 population per year (credibility window = 11.3 - 18.0). The most common reported method of death was self-poisoning (54%). From the case-control study interpersonal difficulties and stressful life events were associated with increased odds of suicide in both confirmed suicides and confirmed combined with suspected suicides. Other pertinent factors such as age and being male differed depending upon which outcome was used.

CONCLUSION

Suicide is common in this area, and interventions are needed to address drivers. The twofold increase in the suicide-specific mortality rate following incorporation of misattributed suicide deaths exemplify underreporting and misclassification of suicide cases at community level. Further, verbal autopsies may underreport suicide specifically among older and female populations.

Gun violence in Australia, 2002-2016: a cohort study

OBJECTIVES

To describe the burden, geographic distribution, and outcomes of firearm-related violence in New South Wales during 2002-2016.

DESIGN, SETTING, PARTICIPANTS

Population-based record linkag study of people injured by firearms in NSW, 1 January 2002 - 31 December 2016.

MAIN OUTCOME MEASURES

Frequency, proportion, and rate of firearm-related injuries and deaths by intent category (assault, intentional self-harm, accidental, undetermined/other) and socio-demographic characteristics; medical service use (hospitalisations, ambulatory mental health care) before and after firearm-related injuries; associations between rates of firearm-related injury and those of licensed gun owners, by statistical area level 4.

RESULTS

Firearm-related injuries were recorded for 2390 people; for 849 people, the injuries were caused by assault (36%), for 797 by intentional self-harm (33%), and for 506 by accidents (21%). Overall rates of firearm injuries were 4.1 per 100 000 males and 0.3 per 100 000 females; the overall rate was higher in outer regional/rural/remote areas (3.8 per 100 000) than in major cities (1.6 per 100 000) or inner regional areas (1.8 per 100 000). During 2002-2016, the overall firearm-related injury rate declined from 3.4 to 1.8 per 100 000 population, primarily because of declines in injuries caused by assault or accidental events. The rate of self-harm injuries with firearms were highest for people aged 60 years or more (41.5 per 100 000 population). Local rates of intentional self-harm injuries caused by firearms were strongly correlated with those of licensed gun owners (r = 0.94).

CONCLUSIONS

Rates of self-harm with firearms are higher for older people, men, and residents in outer regional and rural/remote areas, while those for assault-related injuries are higher for younger people, men, and residents of major cities. Strategies for reducing injuries caused by self-harm and assault with firearms should focus on people at particular risk.

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.

Access to Firearms Among People Assessed by Psychiatric Services in the Emergency Department

OBJECTIVE

In Canada, 80% of firearm-related deaths are suicides. Access to firearms is associated with increased suicide rates. This study examines the frequency and factors that influence assessment of firearm access in an emergency setting.

METHODS

A total of 15,847 consecutive adults seen for psychiatric consultation in two tertiary emergency departments (EDs) in Winnipeg, Manitoba were interviewed. Data captured whether access to firearms was assessed, and whether respondents endorsed access or not. Comparisons were done to determine group differences among those with and without and with known and unknown firearm access.

RESULTS

Access to firearms was unknown in 47% (n = 7,363) of psychiatric ED consultations, including 43% (n = 998) of individuals who presented with a suicide attempt. Female sex was associated with decreased odds of firearm access (odds ratio [OR] 0.28; 95% CI, 0.22 to 0.35). Being single was associated with lower odds of known firearm access (OR 0.83; 95% CI, 0.77 to 0.89) yet higher likelihood of firearm access (OR 1.36; 95% CI, 1.11 to 1.68). Presenting with a suicide attempt (OR 2.45; 95% CI, 1.80 to 3.34), preparatory acts (OR 6.40; 95% CI, 4.38 to 9.36) and suicidal ideation (OR 2.45; 95% CI, 1.87 to 3.21) were associated with increased odds of reporting access. When clinicians felt there was a high likelihood of future suicide, firearm access remained unknown in half of cases.

CONCLUSION

Firearm ownership and access is an essential component of a suicide risk assessment and remains unknown in half of individuals seen by psychiatry in this tertiary care ED sample. People presenting with suicidal ideation and attempts were more likely to report access to firearms.

Firearm Violence: A Global Priority for Nursing Science

PURPOSE

This purpose of this article is to frame firearm violence as a health and public health problem, to illustrate the magnitude of the problem, to examine factors that increase the risk to be injured by a firearm, or conversely, that confer protection, and to identify relevant priority areas for nursing science.

ORGANIZING CONSTRUCT

Firearm violence results in physical and psychological injuries and is a global health priority. Firearm violence is categorized as intentional (interpersonal and self-inflicted) and unintentional (interpersonal and self-inflicted) and accounts for an estimated 196,000 to 220,000 nonconflict deaths annually.

METHODS

We reviewed the theoretical and scientific literature to analyze the magnitude and geographic distribution of firearm violence, the factors associated with firearm injury, the consequences of firearm violence, and areas where nursing science can make an impact on prevention, outcomes, and recovery.

FINDINGS

Firearm violence is a significant public health problem that affects the health of individuals, families, and communities. The burdens and contributors to firearm violence vary worldwide, making it important to understand the local context of this global phenomenon. Relevant areas of inquiry span primary prevention focusing on individual and environmental risk factors; and focus on managing the physical and psychological consequences postinjury; and mitigating long-term consequences of firearm violence.

CONCLUSIONS

Reducing the global burden of firearm violence and improving the health and safety of individuals, families, and communities provide compelling reasons to integrate this area into nursing science.

CLINICAL RELEVANCE

The goals of nursing are to keep people healthy and safe and to help return those injured to their optimal levels of health and well-being. Understanding the factors that come together to injure people with a firearm in various physical, social, economic, and cultural environments positions nurses to both extend the dialogue beyond pro-gun versus anti-gun and to design and carry out rigorous studies to reduce firearm violence.

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.

Firearm legislation, gun violence, and mortality in children and young adults: A retrospective cohort study of 27,566 children in the USA

BACKGROUND

Firearm violence results in the death of thousands of children in the US annually. The effects of firearm legislation on gun violence are published but widely contested.

MATERIALS AND METHODS

The Kid's Inpatient Database from 2000 to 2009 were queried to capture hospitalizations of children diagnosed with a firearm-related injury. Cases were categorized into five levels of firearm legislation strictness by Brady State Scorecard. Trends of injuries were explored in terms of legislative strength, age, and race.

RESULTS

27,566 children analyzed in the study. Most were adolescents aged 15-19 (87.3%), male (89.7%), and black (53.7%). The proportion of accidental injuries increased relative to state law leniency (R² = 0.90), with highest percentage in lenient states (33.2%) compared to strict (16.7%). The proportion of suicide attempts were higher in states with lenient laws (4.4%) compared to strict (1.3%). Accidents were inversely related to age (59.3% in ages 0-4 compared to 22.0% in adolescents), while assaults were positively related to age (31.6% in ages 0-4 compared to 66.6% in adolescents). Whites were most likely to present with accidental injuries (44.6%), and Blacks and Hispanics with assaults (68.2% and 75.6%). Race (p = 0.009), age (p < 0.001), and firearm injury type (p = 0.001) were associated with mortality; Hispanics (OR 1.36, 95% CI: 1.03-1.78), children age 5-9 (2.03, 1.30-3.17) and suicide attempts (15.6, 11.6-20.9) had higher odds of in-hospital mortality.

CONCLUSIONS

Firearm-related injuries types in hospitalized children are associated with age, race, and state level legislation. Accidents are most prevalent in young children, Whites, and states with lenient gun laws, while suicide attempts are more common in adolescents, Whites, and states with lenient gun laws. Suicide attempts are also associated with the greatest odds of in-hospital mortality. To address firearm violence, consideration should be given to legislation that promote safe gun storage behaviors and restrict firearm accessibility to children.

Development of New Quality Measures for Hospital-Based Care of Suicidal Youth

OBJECTIVES

To develop, validate, and test the feasibility of implementation of 4 new quality measures assessing emergency department (ED) and inpatient care for suicidal youth.

METHODS

Four quality measures were developed to assess hospital-based care for suicidal youth. These measures, focused on counseling caregivers about restricting access to lethal means of self-harm and benefits and risks of antidepressant medications, were operationalized into 2 caregiver surveys that assessed ED and inpatient quality, respectively. Survey field tests included caregivers of youth who received inpatient and/or ED care for suicidality at 1 of 2 children's hospitals between July 2013 and June 2014. We examined the feasibility of obtaining measure scores and variation in scores. Multivariate models examined associations between quality measure scores and 4 validation metrics: modified Child Hospital Consumer Assessments of Health Care Providers and Systems, communication composites, hospital readmissions, and ED return visits.

RESULTS

Response rates were 35% (ED) and 31% (inpatient). Most caregivers reported receiving counseling to restrict their child's access to lethal means of self-harm (90% in the ED and 96% in the inpatient setting). In the inpatient setting, caregivers reported higher rates of counseling on benefits (95%) of newly prescribed antidepressants than risks (physical adverse effects 85%, increased suicidality 72%). Higher scores on the latter measure were associated with higher nurse (P < .001) and doctor (P < .01) communication composite scores. Measure scores were not associated with readmissions or ED return visits.

CONCLUSIONS

These new quality measures evaluate key aspects of care for suicidal youth, and they may facilitate assessing quality of care for this vulnerable population.

An analysis of child deaths by suicide in Queensland Australia, 2004-2012. What are we missing from a preventative health services perspective?

BACKGROUND

This article analyzes case descriptions of child suicides from 2004 to 2012 to inform future policy and practice.

METHODS

Quantitative data and case descriptions for 159 child suicides (less than 18 years) in Queensland, Australia, were analyzed quantitatively using SPSS and qualitatively using automated content analysis (Leximancer).

RESULTS

More than three quarters of child suicides involved hanging and 81% of suicides occurred in the family home. Less than 20% of the deceased left a note, however there was evidence of planning in 54% of cases. Most common triggering events were family conflicts.

CONCLUSIONS

Effective suicide prevention interventions require a comprehensive understanding of risk factors. Quality of case descriptions varied widely, which can hamper injury prevention efforts through an incomplete understanding of characteristics of and important factors in child suicide. Additional attention and resources dedicated to this public health issue could enhance the development and implementation of effective intervention strategies targeting child and adolescent suicide.

Northern excess in adolescent male firearm suicides: a register-based regional study from Finland, 1972-2009

There are more firearms in Northern Finland as compared to Southern Finland, and a positive association between suicide rates and the number of firearms in a given region has been demonstrated in previous literature. Accordingly, the authors compared firearm suicide rates of Finnish adolescent (under 18 years) males in the two geographic regions. Young adult (18-24 years) and adult (25-44 years) males were used as reference groups. National data on cases of suicide in Northern and Southern Finland between 1972 and 2009 were obtained from Statistics Finland. Firearm suicides (n=5,423) were extracted according to ICD-classification (ICD-8/9: E955, ICD-10: X72-X75). The distribution of types of firearms (hunting gun, handgun, other) employed in suicides was also investigated. The adolescent male firearm suicide rate in Northern Finland was almost three times higher than that observed in Southern Finland, while there was no difference in rates of suicide by other methods. A northern excess in firearm suicide rates was also found among young adult and adult males. Hunting guns were the most common type of firearms employed in young male suicides, and their use was especially common in Northern Finland. Our results indicate that the use of firearms plays a major role in explaining the northern excess in young Finnish male suicide rates, and emphasize a need to advance suicide prevention according to specific regional characteristics.

Mixed impact of firearms restrictions on fatal firearm injuries in males: a national observational study

Introduction: Public health organizations have recommended restricted access and safe storage practices as means to reduce firearm injuries and deaths. We aimed to assess the effect of four firearm restrictions on firearm deaths in Norway 1969–2009. Methods: All deaths due to firearm discharge were included (5,660 deaths, both sexes). The statistical analysis to assess impact of firearm legislations was restricted to males because of the sex disproportionality (94% were males). Results: A total of 89% of firearm deaths (both sexes) were classified as suicide, 8% as homicide, and 3% as unintentional (accident). During the past four decades, male accidental firearm death rates were reduced significantly by 90%. Male firearms suicide rates increased from 1969 to 1991 by 166%, and decreased by 62% from 1991 to 2009. Despite the great reduction in male accidental firearm deaths, we were unable to demonstrate effects of the laws. In contrast, we found that a 1990 regulation, requiring a police permit before acquiring a shotgun, had a beneficial impact on suicide in the total sample and in those aged 15–34 years. Male firearm homicides decreased post-2003 regulation regarding storing home guard weapons in private homes. Conclusions: Our findings suggest that two laws could have contributed to reduce male firearm mortality. It is, however, a challenge to measure the role of four firearm restrictions. The null findings are inconclusive, as they may reflect no true impact or study limitations.

Factors associated with temporal and spatial patterns in suicide rates across U.S. states, 1976-2000

Using pooled cross-sectional time-series data for the 50 U.S. states over a 25-year period, this article examines how well four conceptual groups of social correlates-demographic, economic, social, and cultural factors-are associated with the 1976-2000 patterns in overall suicide rates and suicide by firearms and other means. Unlike past research that typically considers only one dimension, this analysis differentiates between spatial and temporal variation in suicide rates to determine whether and how social correlates operate differently in these two contexts. Results indicate that suicide rates correspond closely to social correlates. Within U.S. states, lower overall suicide rates between 1976 and 2000 were associated with demographic change (e.g., larger numbers of foreign-born) as well as with fewer numbers of Episcopalians. Across U.S. states, variation in overall suicide rates over the period was related to demographic (percentage male), economic (per capita income), social (percentage divorced), and cultural (alcohol consumption and gun ownership) factors. However, findings differ importantly by type of suicide, and across time and space. Reasons for these distinct patterns are discussed.

Interventions to Prevent Suicide: A Literature Review to Guide Evaluation of California's Mental Health Prevention and Early Intervention Initiative

To help inform the evaluation design for CalMHSA's suicide prevention (SP) and early intervention initiatives, a review of program evaluation literature was done to assess program effectiveness and identify previously used evaluation methodologies. Using evidence from the literature review, the authors provide an overview of the epidemiology of suicides and of non-fatal self-inflicted injuries in California and present a framework for evaluating SP programs, including candidate evaluation measures. The review identified three methodological considerations that can inform the evaluation of SP programs: (1) identifying whether a SP program was effective at reducing suicide deaths is challenging because suicide is such a rare event; (2) SP programs may have differential effects on population subgroups, because suicide rates differ by age, race, and sex; and (3) SP programs may show immediate reductions in suicide attempts but their long-term effects are uncertain. The review also identified two critical gaps in the literature. First, SP evaluation research explores the effects of programs on such outcomes as reduced access to lethal means, provision of care, and crisis response; however, we need to learn more about how these programs influence suicide rates. Second, more research must address the differential effectiveness of SP programs for population subgroups vulnerable to suicide.

Health problems and male firearm suicide

Drawing on constructs of masculinity as it relates to both gun ownership and men's health, we use a rich data set, the New Jersey Violent Death Reporting System as well as hospital discharge data, to analyze 3,413 completed male suicides between the years of 2003 and 2009. We test the hypotheses that the use of firearms is more common when physical health problems are cited as suicide circumstances, and that suicide decedents who use firearms have poorer physical health than those who used other methods. Results show that firearms are disproportionately used in male suicides when physical health is listed as a circumstance. Additionally, among suicide decedents with a hospitalization during the 3 years prior to death, those who used firearms were in poorer health than those who used other methods. These findings have implications for prevention efforts, because restricting access to lethal means is an important aspect of suicide prevention.

Incidence and risk factors of homicide-suicide in Swiss households: National Cohort study

Background

Homicide–suicides are rare but catastrophic events. This study examined the epidemiology of homicide-suicide in Switzerland.

Methods

The study identified homicide–suicide events 1991–2008 in persons from the same household in the Swiss National Cohort, which links census and mortality records. The analysis examined the association of the risk of dying in a homicide–suicide event with socio-demographic variables, measured at the individual-level, household composition variables and area-level variables. Proportional hazards regression models were calculated for male perpetrators and female victims. Results are presented as age-adjusted hazard ratios (HR) with 95% confidence intervals (95%CI).

Results

The study identified 158 deaths from homicide–suicide events, including 85 murder victims (62 women, 4 men, 19 children and adolescents) and 68 male and 5 female perpetrators. The incidence was 3 events per million households and year. Firearms were the most prominent method for both homicides and suicides. The risk of perpetrating homicide-suicide was higher in divorced than in married men (HR 3.64; 95%CI 1.56–8.49), in foreigners without permanent residency compared to Swiss citizens (HR 3.95; 1.52–10.2), higher in men without religious affiliations than in Catholics (HR 2.23; 1.14–4.36) and higher in crowded households (HR 4.85; 1.72–13.6 comparing ≥2 with <1 persons/room). There was no association with education, occupation or nationality, the number of children, the language region or degree of urbanicity. Associations were similar for female victims.

Conclusions

This national longitudinal study shows that living conditions associated with psychological stress and lower levels of social support are associated with homicide-suicide events in Switzerland.

Chances and limits of method restriction: a detailed analysis of suicide methods in Switzerland

The objective of this study was to estimate the potential of method restriction as a public health strategy in suicide prevention. Data from the Swiss Federal Statistical Office and the Swiss Institutes of Forensic Medicine from 2004 were gathered and categorized into suicide submethods according to accessibility to restriction of means. Of suicides in Switzerland, 39.2% are accessible to method restriction. The highest proportions were found in private weapons (13.2%), army weapons (10.4%), and jumps from hot-spots (4.6%). The presented method permits the estimation of the suicide prevention potential of a country by method restriction and the comparison of restriction potentials between suicide methods. In Switzerland, reduction of firearm suicides has the highest potential to reduce the total number of suicides.

Suicide, guns, and public policy

Suicide is a serious public health concern that is responsible for almost 1 million deaths each year worldwide. It is commonly an impulsive act by a vulnerable individual. The impulsivity of suicide provides opportunities to reduce the risk of suicide by restricting access to lethal means. In the United States, firearms, particularly handguns, are the most common means of suicide. Despite strong empirical evidence that restriction of access to firearms reduces suicides, access to firearms in the United States is generally subject to few restrictions. Implementation and evaluation of measures such as waiting periods and permit requirements that restrict access to handguns should be a top priority for reducing deaths from impulsive suicide in the United States.

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

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

Adolescence and the social determinants of health

The health of adolescents is strongly affected by social factors at personal, family, community, and national levels. Nations present young people with structures of opportunity as they grow up. Since health and health behaviours correspond strongly from adolescence into adult life, the way that these social determinants affect adolescent health are crucial to the health of the whole population and the economic development of nations. During adolescence, developmental effects related to puberty and brain development lead to new sets of behaviours and capacities that enable transitions in family, peer, and educational domains, and in health behaviours. These transitions modify childhood trajectories towards health and wellbeing and are modified by economic and social factors within countries, leading to inequalities. We review existing data on the effects of social determinants on health in adolescence, and present findings from country-level ecological analyses on the health of young people aged 10-24 years. The strongest determinants of adolescent health worldwide are structural factors such as national wealth, income inequality, and access to education. Furthermore, safe and supportive families, safe and supportive schools, together with positive and supportive peers are crucial to helping young people develop to their full potential and attain the best health in the transition to adulthood. Improving adolescent health worldwide requires improving young people's daily life with families and peers and in schools, addressing risk and protective factors in the social environment at a population level, and focusing on factors that are protective across various health outcomes. The most effective interventions are probably structural changes to improve access to education and employment for young people and to reduce the risk of transport-related injury.

Suicide methods in Asia: implications in suicide prevention

As the largest continent in the World, Asia accounts for about 60% of World suicides. Preventing suicide by restricting access to suicide methods is one of the few evidence-based suicide prevention strategies. However, there has been a lack of systematic exploration of suicide methods in Asian countries. To amend this shortage, the current review examines the leading suicide methods in different Asian countries, their trend, their age- and sex- specific characteristics, and their implications for suicide prevention. In total, 42 articles with leading suicide methods data in 17 Asian countries/regions were retrieved. The epidemiologic characteristics and recent trends of common suicide methods reflect specific socio-cultural, economic, and religious situations in the region. Common suicide methods shift with the introduction of technologies and constructions, and have specific age- or sex-characteristics that may render the restriction of suicide methods not equally effective for all sex and age sub-groups. Charcoal burning, pesticide poisoning, native plant poisoning, self-immolation, and jumping are all prominent examples. In the information society, suicide prevention that focuses on suicide methods must monitor and control the innovation and spread of knowledge and practices of suicide "technologies". It may be more cost-effective to design safety into technologies as a way of suicide prevention while there is no rash of suicides yet by the new technologies. Further research on suicide methods is important for public health approaches to suicide prevention with sensitivity to socio-cultural, economic, and religious factors in different countries.

Gunshot wound to the eye and orbit: a descriptive case series and literature review

BACKGROUND

The objective of this study is to report ocular and orbital findings in a series of six patients (8 eyes) with gunshot wounds and to review the literature on the pathophysiology, management, and outcome of such patients.

METHODS

Retrospective case series and review of the literature. Main outcome measures were ocular and orbital injury, surgical intervention, and presenting and final visual acuity.

RESULTS

Six male patients (mean age, 32 years) were enrolled. Three patients with globe concussion and low presenting visual acuity were treated by observation. Two patients (25%) underwent primary enucleation or evisceration. Retinal detachment developed in one patient who had a globe perforation, and he underwent vitrectomy and lensectomy with silicone oil injection. Visual acuity remained unchanged in all but one patient who underwent retinal detachment surgery. Final visual acuity was poor in all patients, with five eyes ending in no perception of light. Four patients had orbital fractures, two of whom underwent orbital reconstruction. One of these patients also underwent drainage of orbital abscess, eyelid surgery, and a dacryocystorhinostomy. The mean follow-up time was 26 months.

CONCLUSIONS

Gunshot wounds to the eye and orbit cause severe open and closed ocular injuries with guarded outcome and poor visual acuity. When feasible, initial wound closure may preserve the globe and allow further surgical rehabilitation. Primary evisceration may be required in cases of a severely ruptured globe. Orbital surgery may be needed in cases of infection, orbital wall disruption with disfigurement, or late enophthalmos.

Methods of suicide used by children and adolescents

Although relatively rare, suicide is a leading cause of death in children and adolescents in the Western world. This study examined whether children and adolescents are drawn to other methods of suicide than adults. Swiss suicides from 1998 to 2007 were examined. The main methods of suicide were analysed with respect to age and gender. Of the 12,226 suicides which took place in this 10-year period, 333 were committed by children and adolescents (226 males, 107 females). The most prevalent methods of suicide in children and adolescents 0-19 years were hanging, jumping from heights and railway-suicides (both genders), intoxication (females) and firearms (males). Compared to adults, railway-suicides were over-represented in young males and females (both P < .001). Jumping from heights was over-represented in young males (P < .001). Thus, availability has an important effect on methods of suicide chosen by children and adolescents. Restricting access to most favoured methods of suicide might be an important strategy in suicide prevention.

Controlling access to suicide means

Background: Restricting access to common means of suicide, such as firearms, toxic gas, pesticides and other, has been shown to be effective in reducing rates of death in suicide. In the present review we aimed to summarize the empirical and clinical literature on controlling the access to means of suicide. Methods: This review made use of both MEDLINE, ISI Web of Science and the Cochrane library databases, identifying all English articles with the keywords “suicide means”, “suicide method”, “suicide prediction” or “suicide prevention” and other relevant keywords. Results: A number of factors may influence an individual’s decision regarding method in a suicide act, but there is substantial support that easy access influences the choice of method. In many countries, restrictions of access to common means of suicide has lead to lower overall suicide rates, particularly regarding suicide by firearms in USA, detoxification of domestic and motor vehicle gas in England and other countries, toxic pesticides in rural areas, barriers at jumping sites and hanging, by introducing “safe rooms” in prisons and hospitals. Moreover, decline in prescription of barbiturates and tricyclic antidepressants (TCAs), as well as limitation of drugs pack size for paracetamol and salicylate has reduced suicides by overdose, while increased prescription of SSRIs seems to have lowered suicidal rates. Conclusions: Restriction to means of suicide may be particularly effective in contexts where the method is popular, highly lethal, widely available, and/or not easily substituted by other similar methods. However, since there is some risk of means substitution, restriction of access should be implemented in conjunction with other suicide prevention strategies.

Gun utopias? Firearm access and ownership in Israel and Switzerland

The 2011 attempted assassination of a US representative renewed the national gun control debate. Gun advocates claim mass-casualty events are mitigated and deterred with three policies: (a) permissive gun laws, (b) widespread gun ownership, (c) and encouragement of armed civilians who can intercept shooters. They cite Switzerland and Israel as exemplars. We evaluate these claims with analysis of International Crime Victimization Survey (ICVS) data and translation of laws and original source material. Swiss and Israeli laws limit firearm ownership and require permit renewal one to four times annually. ICVS analysis finds the United States has more firearms per capita and per household than either country. Switzerland and Israel curtail off-duty soldiers' firearm access to prevent firearm deaths. Suicide among soldiers decreased by 40 per cent after the Israeli army's 2006 reforms. Compared with the United States, Switzerland and Israel have lower gun ownership and stricter gun laws, and their policies discourage personal gun ownership.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Firearm suicides and availability of firearms: the Swiss experience

This study aimed to examine the association between the availability of firearms at home, and the proportion of firearm suicides in Switzerland in an ecological analysis. The data series were analysed by canton and yielded a fairly high correlation (Spearman's rho=0.60). Thus, the association holds also at a sub-national level.

Should gun safety be taught in schools? Perspectives of teachers

BACKGROUND

Gun-related injuries and deaths among children occur at disproportionately high rates in the United States. Children who live in homes with guns are the most likely victims. This study describes teachers' views on whether gun safety should be taught to children in the preschool and elementary years.

METHODS

A total of 150 survey questionnaires were distributed to public and private school teachers in preschools and elementary schools in 2 counties of a Midwestern state.

RESULTS

In total, 62% of the 102 respondents indicated that they favored the teaching of gun safety, while 13% disapproved and 25% had no opinion. Overall, 28.4% of the respondents supported the teaching of gun safety in grades pre-K (pre-kindergarten) through first grade. About 54% indicated that police or trained military personnel should do the teaching of this subject in schools, while 6.9% suggested that teachers should do the teaching.

CONCLUSION

With a majority of the teachers in favor of teaching gun safety in the schools, a larger study should be conducted that explores the introduction of gun safety into the curriculum in preschool through grade 6. Such a study should evaluate the efficacy of teaching gun safety as a measure to prevent gun violence and injuries involving guns.

Firearm suicide decedents in the Republic of Ireland, 1980-2005

OBJECTIVES

To compare the sociodemographic characteristics of firearms suicide decedents and other suicide decedents in the Republic of Ireland between 1980 and 2005.

STUDY DESIGN

A cross-sectional study of sociodemographic characteristics of those who committed suicide with a firearm and those who committed suicide by an alternative method.

METHODS

Suicide data from 1980 to 2005 inclusive, provided by the Central Statistics Office of Ireland, were analysed. For the purpose of this paper, suicide method was collapsed into two groups: firearm-assisted suicide (FAS) and non-firearm-assisted suicide (n-FAS). Differences in gender, marital status (married vs not married), area of residence (urban vs rural), agri-employment (agri-employed vs not agri-employed) and age were examined between the two groups. A logistic regression is presented using suicide method (FAS vs n-FAS) as the criterion variable and individual factors as predictors.

RESULTS

In total, 9674 suicides were recorded from 1 January 1980 to 31 December 2005. Seven hundred and ninety-three of these were FAS and 8881 were n-FAS. For both suicide profiles, the deceased were predominantly male, living in a rural setting and not married. However, this profile was more salient in the FAS group. In comparison with the n-FAS group, a greater proportion of the FAS decedents were male [chi(2)(1)=152.5, P< or =0.0001, odds ratio (OR)=4.5, 95% confidence interval (CI) 3.4-6.1], from a rural setting [chi(2)(1)=153.5, P< or =0.0001, OR=4.4, 95%CI 3.2-5.6) and agri-employed [chi(2)(1)=21.3, P< or =0.0001, OR=1.5, 95%CI 1.3-1.8). FAS decedents were significantly younger than n-FAS victims, although the size of this effect was small (z=-8.4, P<0.0005, r=-0.1). There was no difference in marital status between the two groups.

CONCLUSIONS

Risk factors for FAS should inform policy-making in this area, with particular attention paid to protecting young males resident in rural settings. Consideration should be given to targeting agri-employed individuals as a specific at-risk group.

Suicide prevention by limiting access to methods: a review of theory and practice

This review discusses the limitation of access to suicide methods as a way to prevent suicide, an approach which forms a major component of many national suicide prevention strategies. An important distinction is made between efforts that attempt to limit physical access to suicide methods and those that attempt to reduce the cognitive availability of suicide. Physical imitations will be reviewed with reference to restricting access to domestic gas, catalytic converters, firearms, pesticides, jumping, paracetamol and methods used in prisons. Impacts of cognitive availability will be discussed mainly with regard to the media in terms of providing access to technical information and sensational or inaccurate portrayals of suicide. Drawing on psychological models of suicidal ideation and behaviour, this review explores how processes leading to suicidal behaviour and issues around method choice may relate to the effectiveness of limiting access to methods. Potential problems surrounding method limitations are explored, in particular the factors contributing to substitution, the risk that alternative methods of suicide may be used if one is restricted. It is concluded that in appropriate contexts, where substitution is less likely to occur, and in conjunction with psychosocial prevention efforts, limitation of both physical and cognitive access to suicide can be an effective suicide prevention strategy.

Who uses firearms as a means of suicide? A population study exploring firearm accessibility and method choice

BACKGROUND

The 1996 Australian National Firearms Agreement introduced strict access limitations. However, reports on the effectiveness of the new legislation are conflicting. This study, accessing all cases of suicide 1997-2004, explores factors which may impact on the choice of firearms as a suicide method, including current licence possession and previous history of legal access.

METHODS

Detailed information on all Queensland suicides (1997-2004) was obtained from the Queensland Suicide Register, with additional details of firearm licence history accessed from the Firearm Registry (Queensland Police Service). Cases were compared against licence history and method choice (firearms or other method). Odds ratios (OR) assessed the risk of firearms suicide and suicide by any method against licence history. A logistic regression was undertaken identifying factors significant in those most likely to use firearms in suicide.

RESULTS

The rate of suicide using firearms in those with a current license (10.92 per 100,000) far exceeded the rate in those with no license history (1.03 per 100,000). Those with a license history had a far higher rate of suicide (30.41 per 100,000) compared to that of all suicides (15.39 per 100,000). Additionally, a history of firearms licence (current or present) was found to more than double the risk of suicide by any means (OR = 2.09, P < 0.001). The group with the highest risk of selecting firearms to suicide were older males from rural locations.

CONCLUSION

Accessibility and familiarity with firearms represent critical elements in determining the choice of method. Further licensing restrictions and the implementation of more stringent secure storage requirements are likely to reduce the overall familiarity with firearms in the community and contribute to reductions in rates of suicide.

Suicide trends diverge by method: Swiss suicide rates 1969-2005

We examined the change in Swiss suicide rates since 1969, breaking down the rates according to the method used. The descriptive analyses of the main suicide methods are presented. The suicide rates reached a peak in the late 1970s/early 1980s and declined in more recent years. Firearm suicides and suicides by falls were the exception and sustained their upwards trend until the 1990s. Suicide by vehicle exhaust asphyxiation showed a rapid decline following the introduction of catalytic converters in motor vehicles. No substantial method substitution was observed. Suicide by poisoning declined in the 1990s but rose again following an increase in assisted suicide in somatically incurable patients. Suicide is too often regarded as a homogeneous phenomenon. With regard to the method they choose, suicide victims are a heterogeneous population and it is evident that different suicide methods are chosen by different people. A better understanding of the varying patterns of change over time in the different suicide methods used may lead to differentiated preventive strategies.

Methods of suicide: international suicide patterns derived from the WHO mortality database

OBJECTIVE

Accurate information about preferred suicide methods is important for devising strategies and programmes for suicide prevention. Our knowledge of the methods used and their variation across countries and world regions is still limited. The aim of this study was to provide the first comprehensive overview of international patterns of suicide methods.

METHODS

Data encoded according to the International Classification of Diseases (10th revision) were derived from the WHO mortality database. The classification was used to differentiate suicide methods. Correspondence analysis was used to identify typical patterns of suicide methods in different countries by providing a summary of cross-tabulated data.

FINDINGS

Poisoning by pesticide was common in many Asian countries and in Latin America; poisoning by drugs was common in both Nordic countries and the United Kingdom. Hanging was the preferred method of suicide in eastern Europe, as was firearm suicide in the United States and jumping from a high place in cities and urban societies such as Hong Kong Special Administrative Region, China. Correspondence analysis demonstrated a polarization between pesticide suicide and firearm suicide at the expense of traditional methods, such as hanging and jumping from a high place, which lay in between.

CONCLUSION

This analysis showed that pesticide suicide and firearm suicide replaced traditional methods in many countries. The observed suicide pattern depended upon the availability of the methods used, in particular the availability of technical means. The present evidence indicates that restricting access to the means of suicide is more urgent and more technically feasible than ever.

Stemming the Tide of Suicide in Older White Men: A Call to Action

Preventing suicide has been identified as a national priority by recent commissions in the United States. Despite increased awareness of suicide as a public health problem, suicide in older adults remains a neglected topic in prevention strategies and research. This is especially true regarding elderly White men, who in terms of suicide rates have represented the most at-risk age group for the past half century. In light of the unprecedented aging of the United States as the baby boom generation enters late adulthood, suicide prevention initiatives that focus on aging males are needed to prevent a national crisis in geriatric mental health. This article provides a brief review of the perennially under-recognized reality of suicide in older men and prevention strategies that, if implemented, might help stem this rising tide of suicide in this vulnerable population.