1. Firearm Suicide: Risk Factors & Evidence
Beth McGinty, PhD, MS
Assistant Professor, Department of Health Policy and Management
Johns Hopkins Bloomberg School of Public Health
Co-Deputy Director, Center for Mental Health and Addiction Policy Research
DoD/VA Biannual Suicide Prevention Conference
August 1-3, 2017

2. Firearm Violence in the US
Much of the national dialogue focuses on interpersonal violence, particularly mass shootings

3. Firearm Violence in the US
36,252 firearm deaths in the US in 2015
22,018 suicide (61%)
12,979 homicide (36%)
1,255 other (3%)
Sources: National Center for Injury Prevention and Control, CDC. Fatal Injury Reports , for National, Regional, and States (RESTRICTED);

4. Suicide in the US: 2006-2015 Firearm
Source: National Center for Injury Prevention and Control, CDC. Fatal Injury Reports , for National, Regional, and States (RESTRICTED).

5. Suicide Among Active Duty Military and Veterans
Risk of suicide significantly elevated in these groups:
Suicide rate among active duty soldiers: ≈28 per 100,000
Suicide rate among VHA users: ≈39 per 100,000
Research suggests a lower rate among all veterans; highest risk of suicide among younger veterans (i.e. those who served in more recent conflicts)
Suicide rate in US population: ≈13 per 100,000
Sources: National Center for Injury Prevention and Control, CDC. Fatal Injury Reports , for National, Regional, and States (RESTRICTED); Speiss et al. (2015). Surveillance of suicidal behavioral January through December Aberdeen, MD: U.S. Army Public Health Command; U.S. Department of Veteran’s Affairs, Office of Suicide Prevention (2016). Suicide Among Veterans and Other Americans, ; Kaplan et al (2009). Firearm Suicide Among Veterans in the General Population: Findings from the National Violent Death Reporting System. The Journal of Trauma, Injury, Infection and Critical Care, 67 (3): ; Miller et al. (2012). Veterans and Suicide: A Reexamination of the National Death Index – Linked National Health Interview Survey. AJPH 102 (S1): S154-S159. Gibbons et AL (2012). Is the Rate of Suicide Among Veterans Elevated? AJPH, 102 (S1): S17-S19.

6. Risk Factors for Suicide
Mental illness, particularly mood disorders
47-74% of all suicides attributable to mental illness
Substance misuse
Experience of trauma (*can elevate risk indirectly by increasing risk of mental illness)
Social isolation
Economic, employment, familial or other stressors
Access to lethal means
Sources: National Center for Injury Prevention and Control, CDC. Fatal Injury Reports , for National, Regional, and States (RESTRICTED); Speiss et al. (2015). Surveillance of suicidal behavioral January through December Aberdeen, MD: U.S. Army Public Health Command; U.S. Department of Veteran’s Affairs, Office of Suicide Prevention (2016). Suicide Among Veterans and Other Americans, ; Kaplan et al (2009). Firearm Suicide Among Veterans in the General Population: Findings from the National Violent Death Reporting System. The Journal of Trauma, Injury, Infection and Critical Care, 67 (3): ; Miller et al. (2012). Veterans and Suicide: A Reexamination of the National Death Index – Linked National Health Interview Survey. AJPH 102 (S1): S154-S159; Gibbons et al. (2012). Is the Rate of Suicide Among Veterans Elevated? AJPH, 102 (S1): S17-S19.

7. Suicide in the US, by Method - 2015
Source: National Center for Injury Prevention and Control, CDC. Fatal Injury Reports , for National, Regional, and States (RESTRICTED).

8. Lethality of Firearms
85-95% of suicide attempts with firearms are lethal
Compared to 2% for poisoning/overdose
A person’s access to lethal means is a critical factor in whether he or she will survive a suicidal crisis
Suicidal crises peak quickly: 24% of people who survived a suicide attempt reported that <5 minutes passed between deciding to attempt and actual attempt; another 47% reported an hour or less between decision and attempt. Access to a firearm during this window is a key predictor of survival.
What about substitution?
Source: 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, ; Simon et al (2001). Characteristics of impulsive suicide attempts and attempters. SLTB, 32(supp):

9. Gun Access & Suicide
Access to firearms is correlated with the risk of suicide.
Case-control studies in the US have found that the presence of a firearm in the household is a strong risk factor for suicide.
Bullet Point 1 Reference
Anglemyer A, Horvath T, Rutherford G. (2014). The Accessibility of Firearms and Risk for Suicide and Homicide Victimization Among Household Members: A Systematic Review and Meta-analysis. Ann Intern Med. 160(2):
Bullet Point 2 References
Bailey JE, Kellermann AL, Somes GW, Banton JG, Rivara FP, and Rushforth NP. (1997). Risk factors for violent death of women in the home. Arch Intern Med. 157(7):777-82
Brent DA, Perper J, Moritz G, Baugher M, Allman C. (1993). Suicide in adolescents with no apparent psychopathology. J Am Acad Child Adolesc Psychiatry. 32(3):
Brent DA, Perper JA, Allman CJ, Moritz GM, Wartella ME, and Zelenak JP. (1991). The presence and accessibility of firearms in the homes of adolescent suicides. A case control study. JAMA. 266(21):
Brent DA, Perper JA, Goldstein CE, Kolko DJ, Allan MJ, Allman, CJ, and Zelenak JP. (1988). Risk Factors for Adolescent Suicide: A Comparison of Adolescent Suicide Victims With Suicidal Inpatients. Arch Gen Psychiatry. 45(6):
Brent DA, Perper JA, Moritz G, Baugher M, Schweers J, and Roth C. (1993). Firearms and adolescent suicide. A community case-control study. Am J Dis Child. 147(10):
Brent DA, Perper JA, Moritz G, Baugher M, Schweers J, and Roth C. (1994). Suicide in affectively ill adolescents: a case-control study. J Affect Disord. 31(3):
Conwell Y, Duberstein PR, Connor K, Eberly S, Cox C, and Caine ED. (2002). Access to firearms and risk for suicide in middle-aged and older adults. Am J Geriatr Psychiatry. 10(4):
Cummings P, Koepsell TD, Grossman DC, Savarino J, and Thompson RS. (1997). The association between the purchase of a handgun and homicide or suicide. Am J Public Health. 87(6): 974–978.
Kellermann AL, Rivara FP, Somes G, Reay DT, Francisco J, Banton JG, Prodzinski J, Fligner C, and Hackman BB. (1992). Suicide in the Home in Relation to Gun Ownership. N Engl J Med. 327:
Wiebe DJ. (2003). Homicide and suicide risks associated with firearms in the home: a national case-control study. Ann Emerg Med. 41(6):
Shah S, Hoffman RE, Wake L, and Marine WM. (2000). Adolescent suicide and household access to firearms in Colorado: results of a case-control study. J Adolesc Health. 26(3):
Dahlberg LL, Ikeda RM, and Kresnow M. (2004). Guns in the Home and Risk of a Violent Death in the Home: Findings from a National Study. Am J Epidemiol. 160 (10):
Source: Anglemeyer et al (2014). The Accessibility of Firearms and Risk for Suicide and Homicide Victimization among Household Members: A Systematic Review and Meta-Analysis. Ann Intern Med. 160(2):

10. Firearm Suicide among Military and Veteran Populations
Active duty military and veterans are more likely to use firearms in suicide attempts than the general US population
≈66-85% vs. ≈50% of suicide deaths
From , ≈18% of all suicides in the US were among current/former members of the military; 25% of all firearm suicide deaths occurred in these groups
Survey estimates show that about 22% of adults and about 36% of American households own guns
Sources: National Center for Injury Prevention and Control, CDC. Fatal Injury Reports , for National, Regional, and States (RESTRICTED); Kaplan et al (2009). Firearm Suicide Among Veterans in the General Population: Findings from the National Violent Death Reporting System. The Journal of Trauma, Injury, Infection and Critical Care, 67 (3): ; Miller et al. (2012). Veterans and Suicide: A Reexamination of the National Death Index – Linked National Health Interview Survey. AJPH 102 (S1): S154-S159; Hoyt & Duffy (2015). Speiss et al. (2015). Surveillance of suicidal behavioral January through December Aberdeen, MD: U.S. Army Public Health Command; Pruittet al. (2014): Department of Defense Suicide Event Report (DoDSER): Calendar year 2010 annual report. National Center for Telehealth and Technology, Washington, DC.

11. Firearm Suicide among Military and Veteran Populations
Reasons?
High rates of exposure to and comfort with firearms
High rates of gun ownership in this group (44%)
Among active duty military, vast majority of self-inflicted gunshot wounds caused by privately owned, not government issued weapons (92% in 2014)
Survey estimates show that about 22% of adults and about 36% of American households own guns
Sources: Kaplan et al (2009). Firearm Suicide Among Veterans in the General Population: Findings from the National Violent Death Reporting System. The Journal of Trauma, Injury, Infection and Critical Care, 67 (3): ; Miller et al. (2012). Veterans and Suicide: A Reexamination of the National Death Index – Linked National Health Interview Survey. AJPH 102 (S1): S154-S159; Hoyt & Duffy (2015). Speiss et al. (2015). Surveillance of suicidal behavioral January through December Aberdeen, MD: U.S. Army Public Health Command; Pruitt et al. (2014): Department of Defense Suicide Event Report (DoDSER): Calendar year 2010 annual report. National Center for Telehealth and Technology, Washington, DC.

12. Firearm Suicide among Military and Veteran Populations
Reasons?
Diminished fear of death, bodily harm
Interpersonal Psychological Theory of Suicidal Behavior
Suicide attempts using non-firearm means are also more likely to be lethal among military and veteran populations compared to the general US population
Sources: Kaplan et al (2009). Firearm Suicide Among Veterans in the General Population: Findings from the National Violent Death Reporting System. The Journal of Trauma, Injury, Infection and Critical Care, 67 (3): ; Miller et al. (2012). Veterans and Suicide: A Reexamination of the National Death Index – Linked National Health Interview Survey. AJPH 102 (S1): S154-S159; Hoyt & Duffy (2015). Speiss et al. (2015). Surveillance of suicidal behavioral January through December Aberdeen, MD: U.S. Army Public Health Command.

13. Firearm Suicide among Military and Veteran Populations
Summary of Key Points
Elevated risk of suicide among military and veteran groups
Elevated risk of firearm suicide in particular
Access to firearms a significant risk factor for suicide
Suicidal crises are often brief; access to a firearm during a period of crisis a strong predictor of survival
Potential strategies for limiting access to firearms during periods of suicidality?