1. MeansMatter Reducing Access to Lethal Means Issues for Colleges & Universities Catherine Barber Harvard Injury Control Research Center

2. Outline Why Means Matter Evidence that means restriction works (3 studies) Why does it work? Implications for colleges and universities Choose your own adventure: Engaging the gun-owning community as partners in suicide prevention, or Patient scenarios (hand-outs)

3. 1. Coal Gas Before 1960, domestic gas was the leading method of suicide in the United Kingdom. From 1958 to1971, the carbon monoxide content of domestic gas dropped steadily to near zero as new non- toxic (and cheaper) sources of gas replaced the toxic coal gas. Suicide rates dropped by nearly a third. Carbon monoxide (CO) suicides dropped; non-CO suicides increased slightly. Kreitman 1976, Brit J Prev Soc Med.

4. 2. Pesticides – Sri Lanka Pesticides are the leading suicide method in Asia, with an estimated 300,000 deaths annually worldwide. In Sri Lanka, suicide rates rose 8-fold from 1950 to 1995. Restrictions were placed on sales of the most highly human-toxic pesticides in the late ‘90s. Suicide rates dropped 50% from 1996 to 2005. Nonfatal poisonings and suicide by other methods did not drop. Gunnell 2007. Int’l J of Epidemiology.

5. 3. Firearms – Israeli Military The Israeli Defense Force (IDF) is a population-based army with mandatory draft for 18-21 year-olds in Israel. From 2003- 2005, an average of 28 suicides occurred each year, 26 by firearm, many on weekends. In 2006, IDF required soldiers to leave their weapons on base during weekend leaves. The suicide rate decreased by 40%. Weekend suicides dropped significantly. Weekday suicides did not. Lubin 2010, Suic & Life-Threat Behavior.

6. Why Does It Work?

7. The acute phase of a suicidal crisis is often (not always) brief.

8. Suicidal Thoughts Among Students Students who seriously considered attempting suicide in past 12 months Students n=1321 Number of periods 133% 226% 315% 4 or more24% Missing data2% Ave. length of period 1 hour or less31% 2-24 hrs25% 2-7 days27% >1 week16% Drum, Brownson, Denmark, Smith. Professional Psychology: Research & Practice, 2009 n=26,451 students surveyed

9. Another 47% said under an hour. Only 13% said one day or more.

14. Why Did He Survive?

15. Self-Harm Case Fatality Rates Firearms Cutting & Poisoning 85-90% fatal 10-15% nonfatal, ED- treated 1-2% fatal 98% nonfatal, ED-treated Source: CDC WISQARS

16. Self-Harm Case Fatality Rates Firearms Cutting & Poisoning 85-90% fatal 10-15% nonfatal, treated in hospital ER 1-2% fatal 98% nonfatal, treated in hospital ER Source: CDC WISQARS http://www.cdc.gov/ncipc/wisqars/ http://www.cdc.gov/ncipc/wisqars/ NOTE: This information should not be broadly disseminated to general public. People’s perception that overdose and cutting are more lethal than they usually are probably saves many lives.

17. Nonfatal Self-harm Suicide Methods of Self-Harm, U.S. Sources Inpatient: HCUP-NIS (2005). Suicide: CDC WISQARS www.cdc.gov/ncipc/wisqars (2009)www.cdc.gov/ncipc/wisqars Poison 83% Poison 17% Firearm 51% Suffocation 24% Sharp 11% Other 4% Jump 2% Sharp 2% Other 4% Suffocation 1% Firearm 1%

18. But Is It Truly a Life Saved? History of suicide attempt is a risk factor for suicide. What proportion of serious attempters eventually die by suicide? 75% 45% 25% 10% Review of 90 studies: 90% or more of attempters did not go on to die by suicide, even serious attempters such as those jumping in front of a subway and even when followed 10+ years. 20-25% made a nonfatal reattempt. Owens, Br J Psych, 2002.

19. What If He Were a Different Sort? What if he weren’t an angry, impulsive guy? What if he were a 60 year-old who prepared his will, researched his method, set out the bank statements, waited until no one was around? Reducing his access to lethal means might not help. In public health, we work incrementally, finding one set of strategies for one group, another set for another group, chipping away at the problem.

20. Moving Attempters Down the Ladder Firearm Jump from great height Carbon monoxide Hanging/suffocation Overdose/poisoning Cutting High Case Fatality Rate Low Case Fatality Rate

21. Suicidal Behavior (College/Univ Students) Drum, Brownson, Denmark, Smith. New data on the nature of suicidal crises in college students Professional Psychology: Research & Practice, 2009 Among the 5% who seriously considered attempting, past 12 mosn=1321 Began attempt, then stopped15% Actually attempted12%

23. What is it about Firearms? Highly lethal. Fast. Irreversible. No chance for rescue or change of heart once the trigger is pulled. For nearly all other methods except jumps there is an opportunity. Accessible. >1/3 of homes have guns. Acceptable. Some methods, like fire, are entirely accessible but are not acceptable to most U.S. attempters. Leading method. More than all other methods combined.

24. Means Matter The acute phase of a suicidal crisis is often brief. Attempts often involve little deliberation. If a highly lethal method is unavailable, the odds are increased that either a less lethal method will be substituted or the attempt will be delayed. Either option increases the odds of survival. 90% of those making nonfatal attempts will not go on to later die by suicide.

25. Outline Why Means Matter Evidence that means restriction works (3 studies) Why does it work? Implications for colleges and universities Choose your own adventure: Engaging the gun-owning community as partners in suicide prevention, or Patient scenarios (hand-outs)

26. Colleges & Universities Suicide rates among college and university students are low. Their rate is about half that of their non-student peers (Schwartz, Journal of College Health, 2006). Hangings are the leading method for post-secondary education students (NVISS data 2001-2002). Firearms are the leading suicide method for young adults who are not students. Most suicides of post-secondary education students do not occur on campus (NVISS data 2001-2002).

27. Decomposition Approach EXPOSURE Feeling suicidal EVENT Attempt OUTCOME Nonfatal or Fatal

28. Barriers to Means Reduction Assumptions about “intent” (“If you really want to commit suicide, you can always find a way.”) Political contentiousness of gun issue. Assumption that addressing guns must mean advocating for gun control.

29. What Made the Difference? The clinician advised his parents that if they have guns at home, now would be a good time to ask a friend to hold onto them temporarily. Most clinicians do not. Surveys of psychiatrists (HICRC, unpublished), emergency dept nurses (Grossman J, 2003), ED patients (McManus B, 1997), ED child psychiatrists (Giggie 2007) confirm that few clinicians ask about guns and few feel prepared to broach the topic. What would it take to ensure this was standard practice?

30. ED-SAFE Betz M, Miller M, Barber C, et al. Anonymous survey completed by nurses & physicians at 8 EDs (2010/11). Item prompt says, “I ask if there are firearms at home…” and poses patient scenarios. Response categories are “Almost always,” “Often,” “Sometimes,” “Hardly ever.” When Providers Ask about Gun Access

31. “Traditional” suicide screening Do you feel like you want to die, that you want to kill yourself? (if yes, then…) Have you made a plan? (if yes, then…) Do you have access to the means called for in your plan? (if yes, then reduce access) What are the problems with this approach?

32. Suicidal Thoughts Among Students Drum, Brownson, Denmark, Smith. Professional Psychology: Research & Practice, 2009 Among the 5% who seriously considered attempting, past 12 mos Students n=1321 Number of periods 133% 226% 315% 4 or more24% Missing data2% Ave. length of period 1 hr or less31% 2-24 hrs25% 2-7 days27% >1 week16%

33. Suicidal Plans Drum, Brownson, Denmark, Smith. Professional Psychology: Research & Practice, 2009 Among the 5% who seriously considered attempting, past 12 mos Students n=1321 Plans No plan9% Thought about ways, but not seriously54% Had a specific plan37%

34. Suicidal Plans Among Attempters Borges et al. Risk factors for twelve-month suicide attempts in the National Comorbidity Survey Replication (NCS-R). Psychol Med. 2006 Had a Suicide Plan? N=37 People who attempted suicide in past 12 months No plan43% Plan57%

35. Role Play Scenario You’re 19 and you’re flunking out of college, so you were referred to a counselor. You don’t currently feel suicidal but you’re feeling hopeless about the future, you’re in the middle of a painful relationship break-up, and you’re having problems with your family. After a bad argument at home last weekend you wanted to kill yourself and even got as far as looking in the medicine cabinet. You don’t want to talk about this, but will if asked. There are guns at home.

36. Lethal Means Counseling Approach LAST TWO MONTHS - How often in the past couple of months have you felt like you didn’t want to live? Tell me about the times it was the worst. Did you want to kill yourself? EVER ATTEMPTED - Have you ever attempted suicide or started to? TODAY - What about today? Are you thinking about suicide today? IF AT RISK - –Ask about access to firearms, regardless of whether any plans are mentioned. –Ask about plans & about access to methods mentioned.

37. What Made the Difference? The clinician advised his parents that if they have guns at home, now would be a good time to ask a friend to hold onto them temporarily. Most clinicians do not. Surveys of psychiatrists (HICRC, unpublished), emergency dept nurses (Grossman J, 2003), ED patients (McManus B, 1997), ED child psychiatrists (Giggie 2007) confirm that few clinicians ask about guns and few feel prepared to broach the topic. What would it take to ensure this was standard practice?

38. Building It into the System University Health Services Therapist (LICSW) State Social Work Assoc Health Services Administration American College Health Association? Graduate School Change policies & information systems NABITA?

40. Training: CALM-Online Counseling on Access to Lethal Means – Free online training by Harvard, Dartmouth, & SPRC http://training.sprc.org

41. What Providers? School psychologists Truant officer, coach, teacher, principal, nurse Pediatricians ED clinicians Defense attorneys Police Social workers Rehab clinician Employee assistance projects Divorce attorneys, marriage counselors Clergy Nurses Any “gatekeeper”

42. Moving Attempters Down the Ladder Firearm Jump from great height Carbon monoxide Hanging/suffocation Overdose/poisoning Cutting High Case Fatality Rate Low Case Fatality Rate Block access Reduce toxicity Reduce acceptability & knowledge Reduce access to most lethal

43. Environmental Approaches Make changes before a crisis occurs. Environmental changes can prevent accidents too (e.g., preventing drunken falls from rooftops, unintended harm from chemicals) Contagion is a possibility, and highly visible changes in the immediate aftermath of a suicide could draw attention to specific methods. Fences on parking garages and bridges, locked access to rooftops, no guns in dorms, locked lab chemicals.

44. Planned Methods Drum, Brownson, Denmark, Smith. Professional Psychology: Research & Practice, 2009 Among those with a specific suicide plan, past 12 mos Undergrads n=327 Grad students n=137 Overdose51%37% Combination35%24% Cutting26%16% Motor vehicle16%18% Gun15%23% Jump13%3% Other9% Hanging8%6% Asphyxiation4%8% Drowning-5%

45. Prescribing Approaches Your regional poison control center may be able to assist providers on specific quantities. Written resources: –Berman, Shepherd, Silverman, “The LSARS-II” Suicide and Life-Threatening Behavior 2003 (table of substances listing toxicity potential by quantity and patient weight) FOR PROVIDERS ONLY; DO NOT MAKE AVAILABLE ON OPEN WEBSITES Reduce prescribing to non-lethal quantities if a student is at risk; encourage turn-ins for unused meds; don’t publicize lethal combinations.

46. Outline Why Means Matter Evidence that means restriction works (3 studies) Why does it work? Implications for colleges and universities Choose your own adventure: Engaging the gun-owning community as partners in suicide prevention, or Patient scenarios (hand-outs)

47. Political Contentiousness Regions with high gun ownership rates say they can’t touch this topic. Regions with low gun ownership rates say this isn’t their issue. This is everyone’s issue. This is not a legislative issue. How did we save Robert’s life? Not with a change in laws but with a “friends don’t let friends drive drunk” approach.

48. Focusing on Firearms Focusing on firearms looks like “picking on” firearms. In reality it is the “perfect storm” that makes firearms the primary focus of means restriction in this country (leading method, highly lethal, fast, irreversible, accessible, acceptable)

49. What We Want Worried person: “I’m really worried about my brother; he’s drinking so much since he moved in with us, and he’s taking the divorce really hard. He’s told me he’s even thought about suicide.” Neighbor: “Would you like me to hold onto your guns for the time being? Have you asked him if he’d like to talk with a counselor?” The phrases “designated driver” and “friends don’t let friends drive drunk” are ubiquitous now. How do we get that same reach into the gun-owning community and apply the same friends-protecting- friends approach to means restriction?

50. Engaging Gun Owners Gun owners are dying by suicide at higher rates than non-gun owners. Like older white men, people with mental health problems, people with family hx of suicide, etc., gun owners are “our” people. How do we reach them? Do we reach them with an anti-gun agenda? No. That’s like sending an anti-gay group to do a suicide prevention campaign in the gay and lesbian community. A spirit of respectful partnership is key.

51. Natural Alliances Who among your suicide prevention coalitions and networks are gun owners? Use natural networks—hunting clubs, firearm safety classes, gun shops, gun rights clubs, firearm publications/newsletters, etc., to promote suicide awareness as a basic tenet of responsible firearm ownership and firearm safety. If none of your coalition members are gun owners, find natural opportunities to reach out to gun owners for cross-training and cross-fertilization of ideas. (New Hampshire Gun Shop project is a good example.)

52. Suicide Awareness & Means Restriction If people think all suicides involve long deliberation and one method is as likely to kill as another, means restriction will be counter-intuitive. Once people understand some basics about suicide (the episodic and short-term nature of acute suicidal states in some—not all—suicidal people; ambivalence; the higher case fatality rate of firearms), reducing a suicidal person’s access to guns will be more intuitive.

53. Adding a Tenet to Firearm Safety Wherever there is a brochure, website, class, etc., listing rules of firearms safety, work with the sponsors to include a suicide prevention message. If your community does a gun lock giveaway, include a brochure that covers suicide prevention. Most gun safety literature covers only accidents. Messages: –Store firearms locked and unloaded with ammunition locked separately to avoid theft, accident, and suicide of a family member –Consider temporarily storing firearms outside the home if a family member or the gun owner him/herself is at risk for suicide.

54. Questions, Comments? Contact Cathy Barber cbarber@hsph.harvard.edu Visit meansmatter.org Means Matter funded by Joyce and Bohnett Foundations