American Journal of Orthopsychiatry 2015, Vol. 85, No. 3, 221–224
© 2015 American Orthopsychiatric Association http://dx.doi.org/10.1037/ort0000065
COMMENTARY
Preventing the Invisible Plague of Firearm Suicide Carol W. Runyan, Talia L. Brown, and Ashley Brooks-Russell
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Colorado School of Public Health
T
he prominently featured mass shootings in schools in recent years have stimulated new discussion about the issue of firearm-related events in the United States. As the debates about firearms continue, however, one frequent omission from the discussion is the role of firearms in suicide. Even though school shootings represent incredible and shocking tragedies for communities—and often include suicidal behaviors—they represent a tiny fraction of all firearm or suicide deaths. For example, there have been 74 school shootings in the more than 18 months since the shootings at Sandy Hook Elementary School in Newtown, Connecticut, compared to more than 20,000 firearm suicides nationally in 2013 alone. Suicide clearly is a major but underappreciated public health problem. Data from the Centers for Disease Control and Prevention indicate that suicides account for more than 60% of firearm deaths. Among all causes of death in the United States, suicide ranks 10th. In 2013, suicide was responsible for more than 41,149 deaths. That number of
Carol W. Runyan, Departments of Epidemiology and Community and Behavioral Health and Pediatric Injury Prevention, Education and Research (PIPER) Program, Colorado School of Public Health; Talia L. Brown, Department of Epidemiology and Pediatric Injury Prevention, Education and Research (PIPER) Program, Colorado School of Public Health; Ashley BrooksRussell, Department of Community and Behavioral Health and Pediatric Injury Prevention, Education and Research (PIPER) Program, Colorado School of Public Health. We appreciate the help of Marian Betz in reviewing and commenting on a draft of the manuscript. Correspondence concerning this article should be addressed to Carol W. Runyan, 13001 East 17th Place, Mailstop B119, Aurora, CO 80045. E-mail: [email protected]
people would more than fill Fenway Park in Boston. It is a significant number of deaths— more than the number of people who died during the same year as a result of hypertension (30,770), Parkinson’s disease (25,196 deaths) or, notably, homicide (16,121 deaths). Why, then, is suicide not more widely discussed as a public health problem? Unlike homicide, there are no crime shows on TV focused on mental health or suicide. In fact, journalism guidelines created by the American Foundation for Suicide Prevention guide journalists on avoiding extensive and graphic coverage of suicides to reduce copycat events. Although well-reasoned and responsible, restrained media may have had the unintended consequence of reducing the understanding of the magnitude of the problem. Inadequate attention to suicide as a preventable public health issue is likely also the result of other misconceptions and biases. There is a misperception that talking to someone about suicide is not helpful and may actually increase the likelihood that the person will think about it. The reality, however, is that providing the skills to “gatekeepers” (e.g., parents, teachers, coaches, police) for recognizing individuals at risk of suicide, talking with them about their feelings, persuading them to seek help, and referring them to appropriate resources can be an effective way to prevent suicide. Also, there is a commonly held belief that if someone is intent on committing suicide, the person will find a way. However, among those who survive a first attempt, fewer than 10% go on to commit suicide. Particularly for young people, suicide often is an impulsive and ambivalent act. Therefore, if someone is available to support a suicidal individual during his or her time of crisis, that individual is less likely to commit suicide. For this reason, crisis hotlines are a critical part of suicide prevention. 221
There is also an underappreciation among the general public and among health professionals that firearms are implicated in just over half of all suicide deaths. Suicide attempts with firearms are much more lethal than attempts using other methods, with more than 85% of individuals using a firearm dying compared to 2% for individuals using poisoning, 31% by jumping, and 69% by hanging. There is a well-researched and clear connection between access to firearms in the home and an increased risk of firearm suicide of a family member. Additionally, it has long been demonstrated that states and cities with fewer guns have fewer suicides. Consequently, to move forward in preventing firearm suicides, we must first overcome the lack of understanding and find effective and socially and politically acceptable preventive interventions. The remainder of this article focuses on a suggested framework to help with that task.
Strategies for Suicide Prevention As William Haddon articulated decades ago, injury results from the transfer of energy to persons in amounts or at a rate too great for the body to withstand. Although most bodies can withstand the force of a fall onto a soft surface, falls from greater heights or falls onto harder surfaces (more energy transfer) create more injury. Similarly, withstanding the force of a bullet to vital organs is usually fatal. By viewing suicide as a public health problem instead of an isolated individual problem, using Haddon’s logic—that is, reducing the amount of hazard or how the hazard is transmitted to the body—suggests numerous options for prevention. This logic conforms to centuries of public health practice that have shown the most successful prevention efforts are those that make environments safer rather than effecting change
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
222
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solely through modifying the motivations or behaviors of individuals. Examples are numerous, including improving the sanitation of water; building indoor plumbing and sewer systems; constructing safer houses,
Though some will argue that determined individuals will find another method, evidence does not support this. However, the political unacceptability of this option would prohibit its adoption at this point in
Though education of individuals at risk is often a component of successful interventions, rarely is it sufficient to achieve the type of broad-scale population-wide change required for public health soutions roadways, and bridges; placing fluoride in water; and fortifying milk. These successful public health interventions often rely on adopting governmental or organizational policies that allow the environmental change to affect the population universally. Though education of individuals at risk is often a component of successful interventions, rarely is it sufficient to achieve the type of broad-scale population-wide change required for public health solutions. As demonstrated in Table 1, the application of the Haddon Countermeasures to firearms as the “hazard” in the classic sense of environmental hazards—much like chemical hazards (e.g., pesticides), radiation (e.g., nuclear power), or mechanical (e.g., faulty bridge construction) hazards—suggests a number of rarely discussed options for suicide prevention. Haddon’s approach starts with thinking about avoiding creation of the hazard (Countermeasure 1). Obviously, without firearms, there will be no firearm suicides.
time. Consequently, looking to other countermeasures holds more promise. Countermeasure 2 speaks to reducing the number of firearms present in the environment. This raises the politically charged issue of restricting sales to certain individuals—for example, persons with a history of mental illness or of violent episodes. In New Hampshire, a successful program has worked directly with gun dealers to educate them on recognizing individuals in possible mental health crisis and referring them to resources rather than selling guns to them. This initiative was created after three suicides occurred with guns purchased from a single shop, each occurring within hours of purchase. The initial evaluation of the program demonstrates support among gun retailers and sporting organizations and it is being implemented in new locations. Other efforts to legally restrict sales of firearms to persons with a history of mental illness are more complex and controversial. There is a long history of federal regulation
with the goal of keeping firearms away from those with serious mental illness. The vast inadequacies of these regulations resurface as the focus of public attention after any mass shooting. However, there is a lack of evidence that success in keeping firearms from those with serious mental illness will lead to any meaningful decrease in firearmrelated violence and may actually have the unintended consequence of reducing helpseeking by those with mental illness. Haddon’s third countermeasure addresses prevention of the release of the hazard. In the case of preventing firearm suicide, this would mean installing trigger locks so that it is harder to operate the weapon for personal harm. Trigger locks come in several forms with the most common being an external lock on the trigger device. These are relatively inexpensive interventions. Some local and state groups have looked to incentivize or require the distribution of a trigger lock when purchasing a gun. Although several studies have evaluated approaches to distributing and encouraging the use of trigger locks, there have not yet been studies designed to test the effectiveness of trigger locks in prevention of suicide. For example, if the individual at risk of suicide has access to the key to the lock, then the lock is likely of very minimal value for preventing suicide. Countermeasure 4 refers to modifying the rate of release of the hazard from its source. In the case of firearm safety, an example would be reducing the availability of semiautomatic weapons that can do more harm more quickly. However, reducing access to semiautomatic weapons is not likely to affect suicide risk in the way it would for reducing homicide risk.
Table 1. Application of Haddon Countermeasures to Preventing Suicide by Firearm Countermeasure Countermeasure 1: Prevent the creation of the hazard. Countermeasure 2: Reduce the amount of hazard brought into being. Countermeasure 3: Prevent the release of the hazard. Countermeasure 4: Modify the rate of release of the hazard from its source. Countermeasure 5: Separate the hazard from that which is to be protected by time and space. Countermeasure 6: Separate the hazard from that which is to be protected by a physical barrier. Countermeasure 7: Modify relevant basic qualities of the hazard. Countermeasure 8: Make what is to be protected more resistant to damage from the hazard. Countermeasure 9: Begin to counter damage done by the hazard. Countermeasure 10: Stabilize, repair and rehabilitate the object of damage.
Examples related to preventing suicide by firearm Do not produce firearms. Limit the number of firearms allowed to be sold or purchased. Install locks on firearms. Eliminate automatic firearms. Store handguns only at gun clubs rather than at home. Keep firearms unloaded and in locked containers, with ammunition stored separately. Personalize firearms so they can only be fired by the owner. Create and market bullet-proof garments. Provide good access to emergency care in prehospital period. Provide high quality trauma care in hospitals.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
PREVENTING FIREARM SUICIDE
Applying Countermeasure 5 involves separating the hazard from that which is to be protected by time and space. This speaks directly to the approach referred to in the suicide literature as “means restriction”; that is, encouraging families of troubled individuals to store firearms outside the home (e.g., at a gun club or shooting range or with the police), thereby reducing access to the “lethal means.” This approach has shown success in several settings. Our own work with parents of suicidal youth seeking care in a children’s hospital emergency department demonstrated that parents were receptive to receiving counseling about means restriction from mental health professionals during their visit. Others report similar acceptance by patients. A challenge to widespread adoption of this practice is the reluctance of clinicians to see providing such guidance as part of their responsibility in delivering emergency care. Similarly, Countermeasure 6 refers to separating the hazard from that which needs to be protected by a physical barrier. In this case, families that are unwilling or unable to remove firearms from the home are encouraged to be sure that all firearms are safely locked with ammunition stored and locked separately. Of course, to be effective, the suicidal person must not have access to the key or combination. Although better than not locking up firearms at all, there is more opportunity for the individual to find the weapon, circumvent the locks or barriers, and use the weapon than if it is stored remotely. Studies aimed at increasing safe gun storage have shown some success. For example, a study in Alaska succeeded in increasing safe storage of firearms when families were provided with a cabinet. This strategy has not yet been evaluated for reduction of suicide prevention. It is, however, logical to assume it would have positive impact. Applying Countermeasure 7—to modify relevant basic qualities of the hazard—involves changing the gun or ammunition. Technology allowing firearms to be personalized has been available for more than a century. Modern versions are constructed to use fingerprint identification technology or electronic communications that enable the guns to be fired only by persons who are wearing companion devices. Though the major impact of these designs would be on the use of stolen firearms in committing crimes or in preventing unintentional shoot-
223
Suggestions for Further Reading Barber, C. W., & Miller, M. J. (2014). Reducing a suicidal person’s access to lethal means of suicide: a research agenda. American Journal of Preventive Medicine, 24, S264 –S272. Betz, M. E., Miller, M., Barber, C., Miller, I., Sullivan, A. F., Camargo, C. A., Jr., & Boudreaux, E. D. (2013). Lethal means restriction for suicide prevention: Beliefs and behaviors of emergency department providers. Depression and Anxiety, 30, 1013–1020. Grossman, D. C., Cummings, P., Koepsell, T. D., Marshall, J., D’Ambrosio, L., Thompson, R. S., & Mack, C. (2000). Firearm safety counseling in primary care pediatrics: A randomized, controlled trial. Pediatrics, 106, 22–26. Haddon, W. (1973). Energy damage and the 10 countermeasure strategies. Journal of Trauma, 13, 321–331. Mann, J. J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., Haas, A., . . . Hendin, H. (2005). Suicide prevention strategies: A systematic review. Journal of the American Medical Association, 294, 2064 –2074. Miller, M., Azrael, D., & Barber, C. (2012). Suicide mortality in the United States: The importance of attending to method in understanding population-level disparities in the burden of suicide. Annual Review of Public Health, 33, 393– 408. Webster, D. W., & Vernick J. S. (2013). Reducing gun violence in America: Informing policy with evidence and analysis. Baltimore, MD: Johns Hopkins University Press. Wintemute, G. J. (2015). The epidemiology of firearm violence in the twenty-first century United States. Annual Review of Public Health, 36, 5–19. Vriniotis, M., Barber, C., Frank, E., & Demicco, R. (2014). A suicide prevention campaign for firearm dealers in New Hampshire. Suicide and Life-Threatening Behavior. Advance online publication. http://dx.doi.org/10.1111/sltb.12123 Yip, P. S., Caine, E., Yousuf, S., Chang, S.-S., Wu, K. C.-C., & Chen, Y.-Y. (2012). Means restriction for suicide prevention. The Lancet, 379, 2393–2399.
ings by children, it may also have promise in reducing the risk of suicide by household members who are not a designated owner or user of the gun. Currently such guns are not widely available in the United States, however. When applied to the case of firearms and suicides, Countermeasures 8, 9, and 10 extend beyond prevention into mitigating harm. Countermeasure 8 (make what is to be protected more resistant to damage from the hazard) is typically thought of in terms of bolstering the protection of the individual (e.g., through bullet proof clothing worn to prevent damage in an assault). In the case of suicide prevention, this is harder to conceptualize. However, improving the quality and accessibility of mental health care might be seen as a means of strengthening the individual to weather crises without completing a suicide. Countermeasures 9 and 10 refer to health care once a suicide attempt has been made to ensure the best possible treatment and rehabilitation for survivors. Though suicide attempts with firearms are less likely to afford suicidal individuals a second chance, some do survive. Also, those who are suicidal but have not yet made an attempt should be able
to expect accessible, high quality care once they reach an emergency department or mental health provider. In summary, the most viable countermeasures currently are 3, 5, 6, and 7, in addition to continuing broader issues of reducing access to both guns and increasing access to mental health care. Implementing these types of interventions requires policy action to encourage the distribution of gun locks, lock boxes, and personalized firearms, and intervention support for gun safety, including storing guns unloaded, in locked containers, and with ammunition stored separately. It remains critical that the public health and health care systems are involved in supporting families and loved ones in storing guns outside the home of an individual in distress.
Looking Ahead It is encouraging that gun enthusiasts and public health professionals have been able to partner successfully on a gun shop project in New Hampshire in an attempt to reduce firearm purchases by individuals planning a suicide. Other unconventional partnerships between public health profes-
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
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sionals and gun advocates should be investigated. Efforts to encourage physicians to talk about gun ownership with their patients, although challenged through the courts in Florida, remains a recommended method of encouraging attention to safe storage of firearms to reduce suicides by household members. These discussions are likely to influence storage in ways that may also prevent unintentional shootings (e.g., by young children) or homicides in domestic disputes. Recent studies indicate that patients accept the practice of physicians asking about access to firearms in the context of suicide prevention and that at least some providers are willing to add this element of care as routine. Given patient openness, and physician willingness to implement new protocols, hospitals are an ideal place to refocus the issue to mental illness and patient
safety. In Colorado, we have recently embarked on a new study to learn what the barriers and facilitators are for hospitals to adopt this practice as a routine part of discharge from emergency departments. Coupled with these approaches, greater attention surely needs to be paid to the ability of troubled individuals to receive mental health care from qualified professionals. Our health systems need to ensure that health providers are trained in identifying suicidal behaviors and offering appropriate care; the scant research suggests that the training of health care providers in this area is limited. The challenges of getting individuals to seek mental health care require society-wide changes in stigma against those with mental health diagnoses and social norms that run counter to care-seeking, especially among men. We need greater rec-
ognition that behavioral health is part of health care and encourage a nonstigmatized and financially covered approach to care. The media have an important role to play here. Finally, our broader society needs to accept that the protection of troubled individuals is part of our public health responsibility at the community level—just as we care for the safety of our water supply and accept screening at airports to reduce the risk of terrorism. We need to be sure suicide is a visible part of the debate about public health broadly and that suicide prevention is recognized as an important reason for addressing the way in which firearms are sold, stored, and used in America. Keywords: suicide; suicide prevention; firearms; guns; means restriction
© 2015 American Orthopsychiatric Association http://dx.doi.org/10.1037/ort0000065
COMMENTARY
Preventing the Invisible Plague of Firearm Suicide Carol W. Runyan, Talia L. Brown, and Ashley Brooks-Russell
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Colorado School of Public Health
T
he prominently featured mass shootings in schools in recent years have stimulated new discussion about the issue of firearm-related events in the United States. As the debates about firearms continue, however, one frequent omission from the discussion is the role of firearms in suicide. Even though school shootings represent incredible and shocking tragedies for communities—and often include suicidal behaviors—they represent a tiny fraction of all firearm or suicide deaths. For example, there have been 74 school shootings in the more than 18 months since the shootings at Sandy Hook Elementary School in Newtown, Connecticut, compared to more than 20,000 firearm suicides nationally in 2013 alone. Suicide clearly is a major but underappreciated public health problem. Data from the Centers for Disease Control and Prevention indicate that suicides account for more than 60% of firearm deaths. Among all causes of death in the United States, suicide ranks 10th. In 2013, suicide was responsible for more than 41,149 deaths. That number of
Carol W. Runyan, Departments of Epidemiology and Community and Behavioral Health and Pediatric Injury Prevention, Education and Research (PIPER) Program, Colorado School of Public Health; Talia L. Brown, Department of Epidemiology and Pediatric Injury Prevention, Education and Research (PIPER) Program, Colorado School of Public Health; Ashley BrooksRussell, Department of Community and Behavioral Health and Pediatric Injury Prevention, Education and Research (PIPER) Program, Colorado School of Public Health. We appreciate the help of Marian Betz in reviewing and commenting on a draft of the manuscript. Correspondence concerning this article should be addressed to Carol W. Runyan, 13001 East 17th Place, Mailstop B119, Aurora, CO 80045. E-mail: [email protected]
people would more than fill Fenway Park in Boston. It is a significant number of deaths— more than the number of people who died during the same year as a result of hypertension (30,770), Parkinson’s disease (25,196 deaths) or, notably, homicide (16,121 deaths). Why, then, is suicide not more widely discussed as a public health problem? Unlike homicide, there are no crime shows on TV focused on mental health or suicide. In fact, journalism guidelines created by the American Foundation for Suicide Prevention guide journalists on avoiding extensive and graphic coverage of suicides to reduce copycat events. Although well-reasoned and responsible, restrained media may have had the unintended consequence of reducing the understanding of the magnitude of the problem. Inadequate attention to suicide as a preventable public health issue is likely also the result of other misconceptions and biases. There is a misperception that talking to someone about suicide is not helpful and may actually increase the likelihood that the person will think about it. The reality, however, is that providing the skills to “gatekeepers” (e.g., parents, teachers, coaches, police) for recognizing individuals at risk of suicide, talking with them about their feelings, persuading them to seek help, and referring them to appropriate resources can be an effective way to prevent suicide. Also, there is a commonly held belief that if someone is intent on committing suicide, the person will find a way. However, among those who survive a first attempt, fewer than 10% go on to commit suicide. Particularly for young people, suicide often is an impulsive and ambivalent act. Therefore, if someone is available to support a suicidal individual during his or her time of crisis, that individual is less likely to commit suicide. For this reason, crisis hotlines are a critical part of suicide prevention. 221
There is also an underappreciation among the general public and among health professionals that firearms are implicated in just over half of all suicide deaths. Suicide attempts with firearms are much more lethal than attempts using other methods, with more than 85% of individuals using a firearm dying compared to 2% for individuals using poisoning, 31% by jumping, and 69% by hanging. There is a well-researched and clear connection between access to firearms in the home and an increased risk of firearm suicide of a family member. Additionally, it has long been demonstrated that states and cities with fewer guns have fewer suicides. Consequently, to move forward in preventing firearm suicides, we must first overcome the lack of understanding and find effective and socially and politically acceptable preventive interventions. The remainder of this article focuses on a suggested framework to help with that task.
Strategies for Suicide Prevention As William Haddon articulated decades ago, injury results from the transfer of energy to persons in amounts or at a rate too great for the body to withstand. Although most bodies can withstand the force of a fall onto a soft surface, falls from greater heights or falls onto harder surfaces (more energy transfer) create more injury. Similarly, withstanding the force of a bullet to vital organs is usually fatal. By viewing suicide as a public health problem instead of an isolated individual problem, using Haddon’s logic—that is, reducing the amount of hazard or how the hazard is transmitted to the body—suggests numerous options for prevention. This logic conforms to centuries of public health practice that have shown the most successful prevention efforts are those that make environments safer rather than effecting change
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
222
RUNYAN, BROWN, AND BROOKS-RUSSELL
solely through modifying the motivations or behaviors of individuals. Examples are numerous, including improving the sanitation of water; building indoor plumbing and sewer systems; constructing safer houses,
Though some will argue that determined individuals will find another method, evidence does not support this. However, the political unacceptability of this option would prohibit its adoption at this point in
Though education of individuals at risk is often a component of successful interventions, rarely is it sufficient to achieve the type of broad-scale population-wide change required for public health soutions roadways, and bridges; placing fluoride in water; and fortifying milk. These successful public health interventions often rely on adopting governmental or organizational policies that allow the environmental change to affect the population universally. Though education of individuals at risk is often a component of successful interventions, rarely is it sufficient to achieve the type of broad-scale population-wide change required for public health solutions. As demonstrated in Table 1, the application of the Haddon Countermeasures to firearms as the “hazard” in the classic sense of environmental hazards—much like chemical hazards (e.g., pesticides), radiation (e.g., nuclear power), or mechanical (e.g., faulty bridge construction) hazards—suggests a number of rarely discussed options for suicide prevention. Haddon’s approach starts with thinking about avoiding creation of the hazard (Countermeasure 1). Obviously, without firearms, there will be no firearm suicides.
time. Consequently, looking to other countermeasures holds more promise. Countermeasure 2 speaks to reducing the number of firearms present in the environment. This raises the politically charged issue of restricting sales to certain individuals—for example, persons with a history of mental illness or of violent episodes. In New Hampshire, a successful program has worked directly with gun dealers to educate them on recognizing individuals in possible mental health crisis and referring them to resources rather than selling guns to them. This initiative was created after three suicides occurred with guns purchased from a single shop, each occurring within hours of purchase. The initial evaluation of the program demonstrates support among gun retailers and sporting organizations and it is being implemented in new locations. Other efforts to legally restrict sales of firearms to persons with a history of mental illness are more complex and controversial. There is a long history of federal regulation
with the goal of keeping firearms away from those with serious mental illness. The vast inadequacies of these regulations resurface as the focus of public attention after any mass shooting. However, there is a lack of evidence that success in keeping firearms from those with serious mental illness will lead to any meaningful decrease in firearmrelated violence and may actually have the unintended consequence of reducing helpseeking by those with mental illness. Haddon’s third countermeasure addresses prevention of the release of the hazard. In the case of preventing firearm suicide, this would mean installing trigger locks so that it is harder to operate the weapon for personal harm. Trigger locks come in several forms with the most common being an external lock on the trigger device. These are relatively inexpensive interventions. Some local and state groups have looked to incentivize or require the distribution of a trigger lock when purchasing a gun. Although several studies have evaluated approaches to distributing and encouraging the use of trigger locks, there have not yet been studies designed to test the effectiveness of trigger locks in prevention of suicide. For example, if the individual at risk of suicide has access to the key to the lock, then the lock is likely of very minimal value for preventing suicide. Countermeasure 4 refers to modifying the rate of release of the hazard from its source. In the case of firearm safety, an example would be reducing the availability of semiautomatic weapons that can do more harm more quickly. However, reducing access to semiautomatic weapons is not likely to affect suicide risk in the way it would for reducing homicide risk.
Table 1. Application of Haddon Countermeasures to Preventing Suicide by Firearm Countermeasure Countermeasure 1: Prevent the creation of the hazard. Countermeasure 2: Reduce the amount of hazard brought into being. Countermeasure 3: Prevent the release of the hazard. Countermeasure 4: Modify the rate of release of the hazard from its source. Countermeasure 5: Separate the hazard from that which is to be protected by time and space. Countermeasure 6: Separate the hazard from that which is to be protected by a physical barrier. Countermeasure 7: Modify relevant basic qualities of the hazard. Countermeasure 8: Make what is to be protected more resistant to damage from the hazard. Countermeasure 9: Begin to counter damage done by the hazard. Countermeasure 10: Stabilize, repair and rehabilitate the object of damage.
Examples related to preventing suicide by firearm Do not produce firearms. Limit the number of firearms allowed to be sold or purchased. Install locks on firearms. Eliminate automatic firearms. Store handguns only at gun clubs rather than at home. Keep firearms unloaded and in locked containers, with ammunition stored separately. Personalize firearms so they can only be fired by the owner. Create and market bullet-proof garments. Provide good access to emergency care in prehospital period. Provide high quality trauma care in hospitals.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
PREVENTING FIREARM SUICIDE
Applying Countermeasure 5 involves separating the hazard from that which is to be protected by time and space. This speaks directly to the approach referred to in the suicide literature as “means restriction”; that is, encouraging families of troubled individuals to store firearms outside the home (e.g., at a gun club or shooting range or with the police), thereby reducing access to the “lethal means.” This approach has shown success in several settings. Our own work with parents of suicidal youth seeking care in a children’s hospital emergency department demonstrated that parents were receptive to receiving counseling about means restriction from mental health professionals during their visit. Others report similar acceptance by patients. A challenge to widespread adoption of this practice is the reluctance of clinicians to see providing such guidance as part of their responsibility in delivering emergency care. Similarly, Countermeasure 6 refers to separating the hazard from that which needs to be protected by a physical barrier. In this case, families that are unwilling or unable to remove firearms from the home are encouraged to be sure that all firearms are safely locked with ammunition stored and locked separately. Of course, to be effective, the suicidal person must not have access to the key or combination. Although better than not locking up firearms at all, there is more opportunity for the individual to find the weapon, circumvent the locks or barriers, and use the weapon than if it is stored remotely. Studies aimed at increasing safe gun storage have shown some success. For example, a study in Alaska succeeded in increasing safe storage of firearms when families were provided with a cabinet. This strategy has not yet been evaluated for reduction of suicide prevention. It is, however, logical to assume it would have positive impact. Applying Countermeasure 7—to modify relevant basic qualities of the hazard—involves changing the gun or ammunition. Technology allowing firearms to be personalized has been available for more than a century. Modern versions are constructed to use fingerprint identification technology or electronic communications that enable the guns to be fired only by persons who are wearing companion devices. Though the major impact of these designs would be on the use of stolen firearms in committing crimes or in preventing unintentional shoot-
223
Suggestions for Further Reading Barber, C. W., & Miller, M. J. (2014). Reducing a suicidal person’s access to lethal means of suicide: a research agenda. American Journal of Preventive Medicine, 24, S264 –S272. Betz, M. E., Miller, M., Barber, C., Miller, I., Sullivan, A. F., Camargo, C. A., Jr., & Boudreaux, E. D. (2013). Lethal means restriction for suicide prevention: Beliefs and behaviors of emergency department providers. Depression and Anxiety, 30, 1013–1020. Grossman, D. C., Cummings, P., Koepsell, T. D., Marshall, J., D’Ambrosio, L., Thompson, R. S., & Mack, C. (2000). Firearm safety counseling in primary care pediatrics: A randomized, controlled trial. Pediatrics, 106, 22–26. Haddon, W. (1973). Energy damage and the 10 countermeasure strategies. Journal of Trauma, 13, 321–331. Mann, J. J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., Haas, A., . . . Hendin, H. (2005). Suicide prevention strategies: A systematic review. Journal of the American Medical Association, 294, 2064 –2074. Miller, M., Azrael, D., & Barber, C. (2012). Suicide mortality in the United States: The importance of attending to method in understanding population-level disparities in the burden of suicide. Annual Review of Public Health, 33, 393– 408. Webster, D. W., & Vernick J. S. (2013). Reducing gun violence in America: Informing policy with evidence and analysis. Baltimore, MD: Johns Hopkins University Press. Wintemute, G. J. (2015). The epidemiology of firearm violence in the twenty-first century United States. Annual Review of Public Health, 36, 5–19. Vriniotis, M., Barber, C., Frank, E., & Demicco, R. (2014). A suicide prevention campaign for firearm dealers in New Hampshire. Suicide and Life-Threatening Behavior. Advance online publication. http://dx.doi.org/10.1111/sltb.12123 Yip, P. S., Caine, E., Yousuf, S., Chang, S.-S., Wu, K. C.-C., & Chen, Y.-Y. (2012). Means restriction for suicide prevention. The Lancet, 379, 2393–2399.
ings by children, it may also have promise in reducing the risk of suicide by household members who are not a designated owner or user of the gun. Currently such guns are not widely available in the United States, however. When applied to the case of firearms and suicides, Countermeasures 8, 9, and 10 extend beyond prevention into mitigating harm. Countermeasure 8 (make what is to be protected more resistant to damage from the hazard) is typically thought of in terms of bolstering the protection of the individual (e.g., through bullet proof clothing worn to prevent damage in an assault). In the case of suicide prevention, this is harder to conceptualize. However, improving the quality and accessibility of mental health care might be seen as a means of strengthening the individual to weather crises without completing a suicide. Countermeasures 9 and 10 refer to health care once a suicide attempt has been made to ensure the best possible treatment and rehabilitation for survivors. Though suicide attempts with firearms are less likely to afford suicidal individuals a second chance, some do survive. Also, those who are suicidal but have not yet made an attempt should be able
to expect accessible, high quality care once they reach an emergency department or mental health provider. In summary, the most viable countermeasures currently are 3, 5, 6, and 7, in addition to continuing broader issues of reducing access to both guns and increasing access to mental health care. Implementing these types of interventions requires policy action to encourage the distribution of gun locks, lock boxes, and personalized firearms, and intervention support for gun safety, including storing guns unloaded, in locked containers, and with ammunition stored separately. It remains critical that the public health and health care systems are involved in supporting families and loved ones in storing guns outside the home of an individual in distress.
Looking Ahead It is encouraging that gun enthusiasts and public health professionals have been able to partner successfully on a gun shop project in New Hampshire in an attempt to reduce firearm purchases by individuals planning a suicide. Other unconventional partnerships between public health profes-
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
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sionals and gun advocates should be investigated. Efforts to encourage physicians to talk about gun ownership with their patients, although challenged through the courts in Florida, remains a recommended method of encouraging attention to safe storage of firearms to reduce suicides by household members. These discussions are likely to influence storage in ways that may also prevent unintentional shootings (e.g., by young children) or homicides in domestic disputes. Recent studies indicate that patients accept the practice of physicians asking about access to firearms in the context of suicide prevention and that at least some providers are willing to add this element of care as routine. Given patient openness, and physician willingness to implement new protocols, hospitals are an ideal place to refocus the issue to mental illness and patient
safety. In Colorado, we have recently embarked on a new study to learn what the barriers and facilitators are for hospitals to adopt this practice as a routine part of discharge from emergency departments. Coupled with these approaches, greater attention surely needs to be paid to the ability of troubled individuals to receive mental health care from qualified professionals. Our health systems need to ensure that health providers are trained in identifying suicidal behaviors and offering appropriate care; the scant research suggests that the training of health care providers in this area is limited. The challenges of getting individuals to seek mental health care require society-wide changes in stigma against those with mental health diagnoses and social norms that run counter to care-seeking, especially among men. We need greater rec-
ognition that behavioral health is part of health care and encourage a nonstigmatized and financially covered approach to care. The media have an important role to play here. Finally, our broader society needs to accept that the protection of troubled individuals is part of our public health responsibility at the community level—just as we care for the safety of our water supply and accept screening at airports to reduce the risk of terrorism. We need to be sure suicide is a visible part of the debate about public health broadly and that suicide prevention is recognized as an important reason for addressing the way in which firearms are sold, stored, and used in America. Keywords: suicide; suicide prevention; firearms; guns; means restriction
