> There's been a lot in print recently about the connections
> between gun ownership and suicide.
>
>The connection has historically been that in places where guns are
>easy to get, the gun is the tool of choice for suicide; in places
>where they are hard to get, they aren't. So? The real question
>is: in the places where it suddenly gets hard to get guns, what
>happens to the suicide rate? The answer is that that it's doesn't
>affect it. There's a substitution effect; if you can't get a gun
>in Canada, you use a knife or pills. That is: access to gun is
>not a determining factor in suicide.
[An abstract and related editorial from this week's (November 18) New England Journal of Medicine:]
[ARTICLE - ABSTRACT]
MORTALITY AMONG RECENT PURCHASERS OF HANDGUNS
GAREN J. WINTEMUTE, M.D., M.P.H., CARRIE A. PARHAM, M.S., JAMES JAY BEAUMONT, PH.D., MONA WRIGHT, M.P.H., AND CHRISTIANA DRAKE, PH.D.
BACKGROUND There continues to be considerable controversy over whether ownership of a handgun increases or decreases the risk of violent death.
METHODS We conducted a population -based cohort study to compare mortality among 238,292 persons who purchased a handgun in California in 1991 with that in the general adult population of the state. The observation period began with the date of handgun purchase (15 days after the purchase application) and ended on December 31, 1996. The standardized mortality ratio (the ratio of the number of deaths observed among handgun purchasers to the number expected on the basis of age- and sex-specific rates among adults in California) was the principal outcome measure.
RESULTS In the first year after the purchase of a handgun, suicide was the leading cause of death among handgun purchasers, accounting for 24.5 percent of all deaths and 51.9 percent of deaths among women 21 to 44 years old. The increased risk of suicide by any method among handgun purchasers (standardized mortality ratio, 4.31) was attributable entirely to an excess risk of suicide with a firearm (standardized mortality ratio, 7.12). In the first week after the purchase of a handgun, the rate of suicide by means of firearms among purchasers (644 per 100,000 person- years) was 57 times as high as the adjusted rate in the general population. Mortality from all causes during the first year after the purchase of a handgun was greater than expected for women (standardized mortality ratio, 1.09), and the entire increase was attributable to the excess number of suicides by means of a firearm. As compared with the general population, handgun purchasers remained at increased risk for suicide by firearm over the study period of up to six years, and the excess risk among women in this cohort (standardized mortality ratio, 15.50) remained greater than that among men (standardized mortality ratio, 3.23). The risk of death by homicide with a firearm was elevated among women (standardized mortality ratio at one year, 2.20; at six years, 2.01) but low among men (standardized mortality ratio at one year, 0.84; at six years, 0.79).
CONCLUSIONS The purchase of a handgun is associated with a substantial increase in the risk of suicide by firearm and by any method. The increase in the risk of suicide by firearm is apparent within a week after the purchase of a handgun and persists for at least six years. (N Engl J Med 1999;341:1583-9.)
---
[EDITORIAL]
FIREARMS AND SUICIDE
THE article by Wintemute et al.1 in this issue of the journal adds to the growing literature that connects firearms with increased risks of suicide and homicide.2-6 Some of these studies have examined the risks associated with the possession of firearms, and some, the risks associated with ownership; now, this article looks at the risks in relation to firearm purchase. The findings are of particular interest because they indicate that purchasers of handguns are at high risk for suicide, particularly during the period immediately after the purchase.1 This association is especially strong among women.
There are other interesting findings in this study, as well as limitations. First, it is important to note that Wintemute et al. found that the risk of death from homicide among men who purchased handguns was actually lower than that among men in the general population. Although this finding did not apply to women who purchased a handgun, it may represent a true protective effect of handgun purchase and needs to be considered seriously and examined further. Second, the current findings do not demonstrate that the purchase of a firearm caused suicidal behavior or actually increased the risk of suicide among those who purchased handguns. Causes of suicidal behavior may include a variety of factors, ranging from depression and schizophrenia to a history of domestic violence or child abuse to impulsivity.7 Previous research indicates, however, that firearms are more likely to be lethal than other commonly used methods of attempting suicide.8-10 The data presented by Wintemute et al. suggest that people who are considering suicide may purchase a firearm in order to carry out their plan with the most lethal means available. This possibility challenges us to find a way to prevent such purchasers of handguns from committing suicide.
This is a serious challenge. The report by Wintemute et al. highlights the importance of firearm-related suicide as a critical component of the overall problem of firearm-related injuries. In fact, the most common cause of firearm-related deaths in this country is suicide. In 1997 in the United States, 32,436 people died from firearm injuries: 17,566 (54 percent) of these deaths were suicides and 13,252 (41 percent) were homicides. Despite these numbers, suicides by firearm have been virtually ignored in most discussions of how to prevent firearm-related violence.
We believe there are several explanations for this lack of attention. First, most people are not aware of how many suicides are committed with handguns. Second, when people think of "handgun violence," they often think only of homicide, and because media attention is focused primarily on homicide, suicide is less visible and inherently less threatening.
Third, many people are fatalistic about suicide, believing that little can be done to stop a person who is intent on committing suicide from doing so. In addition, it is commonly believed that the chosen method of suicide is not an important determinant of the outcome. Many people believe that access to firearms is of little consequence in this regard because people who are suicidal are so intent on killing themselves that they will find another means of doing so if a firearm is not readily available.
Fourth, those who study the prevention of firearm-related violence are usually separate from those who study the prevention of suicide in general. Firearm-related violence has traditionally been the domain of criminal justice, whereas suicide has been seen as part of mental health care. Wintemute et al. represent a new breed of public health professional, successfully bringing these two domains together to raise new questions and stimulate new responses.
The report by Wintemute et al. should make us ask, "What do we need to know and what do we need to do to prevent firearm-related suicides?" To seek answers, three areas need to be explored: What do we know about the frequency and characteristics of suicides by firearm? What are the causes of firearm suicides? And what interventions are effective in the prevention of firearm suicides?
First, we need to understand more about the circumstances under which suicides by firearm occur. Do those who commit suicide by this method have a history of domestic violence, child abuse, or depression? Have persons who committed suicide with firearms recently been involved in an interpersonal conflict, or have they suffered a traumatic loss? And what do we know about the firearms used to commit suicide? Information about the types of firearms, their storage, and their history of ownership and ownership transfer would be useful in developing strategies for prevention. For recent purchasers of handguns who used a handgun to commit suicide, was the handgun they used the same one that they purchased recently? How can we use the methods developed by the Bureau of Alcohol, Tobacco, and Firearms for tracing firearm purchases in homicides and other crimes to examine these connections?
The study by Winternute et al. included only adults, since only adults can legally purchase handguns. We need to look at the circumstances under which children and adolescents with suicidal thoughts obtain handguns originally purchased through legal channels or acquired through illegal channels. Progress in this area will require collecting data on large numbers of firearm purchases and firearm-related injuries. Winternute et al. have been able to conduct many productive studies in this respect because California systematically collects data and makes them available for research. There have been multiple calls for a system of firearm-injury surveillance to ensure the collection of such data at a relatively low cost.11,12 Such a system would permit more systematic analysis and help to prevent firearm- related injuries and deaths.
Second, we need to understand a great deal more about the causes of firearm-related suicide, in particular how handgun purchase is related to suicidal behavior. For example, would persons who try to purchase a handgun with the intention of using it to commit suicide be successful in committing suicide if they were prevented from purchasing the gun? Are depression and other forms of mental illness important risk factors for firearm-related suicide among purchasers of handguns, or are handgun purchasers who are suicidal more likely to be characterized by impulsivity? Immediate access to a firearm may be a much more important risk factor for someone who is impulsive than for someone who is seriously depressed. The high risk that might be posed by impulsivity would not just be the risk associated with the impulse to purchase the handgun, but might also reflect the high risk associated with the impulse to use the handgun if it were available. Does violence perpetrated by an intimate partner play a part in suicidal behavior among women who purchase guns? Since Winternute et al. found that only about 10 percent of all suicides by firearm were committed by recent purchasers of handguns, how did the other 90 percent of persons who committed suicide with a firearm gain access to the weapon?
Finally, at the time a handgun is purchased, there are often processes in place (such as waiting periods and background checks) that may help prevent suicide, but their effectiveness has not been evaluated. Do waiting periods prevent suicides among people who are impulsive by preventing them from having access to a handgun during the time they have the suicidal impulse? If waiting periods do prevent impulsive suicides, what is the optimal length of a waiting period for the prevention of the greatest number of these suicides? Can background checks be used to identify persons who are at high risk for suicidal behavior?
There do not appear to be any screening instruments for suicidal tendency that are sufficiently specific for use in preventing persons who are suicidal from taking possession of a firearm at the time of sale. The problem is that suicide is so rare among handgun purchasers that even a highly specific screening tool would yield many more false positives than it would identify real cases, so screening is probably not a good option.1 Would it be more effective to screen all purchasers for mental health problems with the use of a questionnaire at the time of sale?
The issue is no longer whether we should apply science to the problem of firearm-related injuries, but how we should do so in the effort to prevent such injuries. Eleven years ago, an editorial in the Journal called for more scientific investigation of firearm injuries,13 as did a recent report by the Institute of Medicine.12 Kassirer14 has called on the government, together with foundations and the private sector, to intensify efforts to describe the problem, identify risks and protective factors, and evaluate strategies for prevention. Scientific investment in this area remains limited despite the magnitude of the problem. Expanding efforts to answer some of the questions we have posed here may help to preserve the legality of firearm ownership while saving many lives. To use science to answer these questions is only common sense. We cannot afford not to do so.
MARK L. ROSENBERG, M.D., M.P.P. Collaborative Center for Child Well-being Decatur, GA 30030
JAMES A. MERCY, PH.D. Medical College of Wisconsin Milwaukee, W1 53226
LLOYD B. POTTER, PH.D., M.P.H. Centers for Disease Control and Prevention Atlanta, GA 30341
REFERENCES
1. Wintemute GJ, Parham CA, Beaumont JJ, Wright M, Drake C. Mortality among recent purchasers of handguns. N Engl J Med 1999;341:1583-9.
2. Brent DA, Perper JA, Goldstein CE, et al. Risk factors for adolescent suicide: a comparison of adolescent suicide victims with suicidal inpatients. Arch Gen Psychiatry 1988;45:581-8.
3. Brent DA, Perper JA, Allman CJ, Moritz GM, Wartella ME, Zelenak JP. The presence and accessibility of firearms in the homes of adolescent suicides: a case-control study. JAMA 1991;266:2989-95.
4. Kellermann AL, Rivara FP, Somes G, et al. Suicide in the home in relation to gun ownership. N Engl J Med 1992;327:467-72.
Kellermann AL, Rivara FP, Rushforth NB, et al. Gun ownership as a risk factor for homicide in the home. N Engl J Med 1993;329:1084-91. 6. Cummings P, Koepsell TD, Grossman DC, Savarino J, Thompson RS. The association between the purchase of a handgun and homicide or suicide. Am J Public Health 1997;87:974-8.
7. The Surgeon General's call to action to prevent suicide. Washington, D.C.: Public Health Service, 1999.
8. Annest JL, Mercy JA, Gibson DR, Ryan GW National estimates of nonfatal firearm-rclated injuries: beyond the tip of the iceberg. JAMA 1995;273:1749-54.
9. Card JJ. Lethality of suicidal methods and suicide risk: two distinct concepts. omega J Death Dying 1974;5(l):37-45.
10. Lee RK, Waxweiler RJ, Dobbins JG, Paschetag T. Incidence rates of firearm injuries in Galveston, Texas, 1979-1981. Am J Epidemiol 1991; 134:511-21.
11. Teret SR The firearm injury reporting system revisited. JAMA 1996; 275:70.
12. Bonnie BJ, Fulco CE, Liverman CT, eds. Reducing the burden of injury: advancing prevention and treatment. Washington, D.C.: National Academy Press, 1999.
13. Mercy JA, Houk VN. Firearm injuries: a call for science. N Engl J Med 1988;319:1283-5.
14. Kassirer JP. A partisan assault on science - the threat to the CDC. N Engl J Med 1995;333:793-4.