Introduction

In this chapter, the evidence linking firearms in the home to risk for suicide will be reviewed. These data come from epidemiological, case-control, quasi-experimental, and prospective studies. The convergent finding from this wide range of studies is that there is a strong relationship between firearms in the home and risk for suicide, most firmly established in United States.

Epidemiological Studies

Epidemiological studies have consistently shown that firearms are most common method of suicide for all demographic groups in the United States (CDC, 1994). The dramatic increase in the American youth suicide rate since 1960 is primarily attributable to an increase in suicide by firearms (Boyd, 1983; Boyd &Mosciski, 1986; see Figs. 1 and 2). In one study of youth suicide in Allegheny County from 1960-1983, the rate of suicide by firearms increased 330%, but the rate of suicide by other means only increased 150% (Brent et al., 1987). The more recent increase in the suicide rate by African American males is also attributable primarily to an increase in suicide by firearms.

There is evidence of a relationship between the increasing prevalence of alcohol abuse in adolescents over this period of time and the increase in suicide by firearms. First, the proportion of youthful suicide victims who were drinking at the time of the suicide has increased dramatically over the two decades beginning in 1960 (Brent et al., 1987; Ford et al., 1979). In turn, those youth who were drinking at the time of their suicide were much more likely to use a gun than were youth who were not drinking (Brent et al., 1987, 1993a; Hlady & ; Middaugh, 1988). This finding is consistent with the observation that alcohol and illicit drug abuse in the home greatly increases the risk of violent death, including suicide (Rivara et al., 1997).

Furthermore, these findings suggest that the increase in youth alcohol abuse and in firearms availability over the past 3 decades may be related to the increase in youth suicide in general, and in youth firearms suicide in specific. However, it is important to note that youth suicide has also dramatically increased in geographic regions where firearms ownership and firearms suicides are relatively rare (e.g., New Zealand) (Beautrais et al., 1996).

Therefore, it would be an oversimplification to say that the increase in youth suicide, in the United States, or anywhere else in the world, is solely a function of increased firearms availability.

Case-control studies

Case-control studies performed in the United States have consistently shown a relationship between the presence of guns in the home and completed suicide. It is important to note that in a case-control study, one can only establish the relative prevalence of guns in the homes of suicides vs. controls, and assume that, if the sampling is performed without bias, that this odds ratio is an estimate of the relative risk that having a gun in the home conveys for suicide.

Several case-control studies have been conducted comparing the prevalence of firearms in the homes of suicide victims and matched, living controls. (Beautrais et al., 1996; Brent et al., 1988, 1991, 1993a, Kellermann et al., 1992). These studies have focused on youth suicide primarily, although one, the largest by far, encompassed the entire lifespan (Kellermann et al., 1992). In the Kellerman et al. (1992) study, in contra-distinction to the others, only suicides that occurred in the home were studied.

All were conducted in he United States, with the exception of the study of Beautrais et al. (1996) which was conducted in New Zealand. Issues that were addressed (to a variable degree) in these studies were: (1) the likelihood that, if a gun was in the home, it was used for the suicide; (2) whether gun was purchased recently for the express purpose of committing suicide; (3) the relative prevalence of guns in the homes of suicides and controls; (4) the impact of gun-related variables on suicidal risk (e.g, type of guns, number of guns, method of storage); and (5) the influence of demographic and psychiatric variables on the relationship between guns and risk for suicide.

With respect to these case-control studies, all the above-noted studies show that the presence of a gun in the home is highly predictive of its use for completed suicide (See Table 1). If a gun was already in the home, the odds of the gun being used for the suicide ranged between 31.1-107.9. This was even true in New Zealand, where firearms is a much less common method choice for suicide than in the United States (14% vs. 55-60%; Beautrais et al., 1996). Conversely, if a gun was not in the home, it was used as a method of suicide quite infrequently. Furthermore, in the one study that examined this issue, only 3% of the suicide sample of Kellermann et al. (1992) had bought a gun within two weeks of the suicide.

These data strongly suggest that it is the immediate gun availability that conveys the risk for firearms suicide, supports method restriction as one means to prevent firearms suicide.

With regard to the odds of association between guns in the home and suicide, all the American studies have found a significant association between guns in the home and suicide. Two American studies of adolescent suicides, with referred suicide attempters and non-attempter psychiatric patients as controls found an odds ratio in the range of 2-3 (Brent et al., 1988, 1991). In studies comparing suicides to a community sample of controls, and adjusting for potentially confounding variables like psychopathology, guns were 4-5 times more likely to be found in the home of suicide victims than in the homes of community controls (Brent et al., 1993a;

Kellermann et al., 1992). Of interest is that firearms variables were unrelated to parental or adolescent psychopathology, and therefore appear to convey risk relatively independently of these important risk factors (Brent et al., 1991, 1993a). In the New Zealand study, the odds of association were in the predicted direction, but escaped statistical significance (OR=1.4). Beautrais et al. (1996) speculated that the paucity of firearms in the homes in New Zealand, along with its relative rarity as a method of suicide mitigated against finding an association. These results, at variance with American studies, indicate that cultural factors can clearly moderate the relationship between gun availability and risk for suicide.

While there is a relationship between guns in the home and suicide, regardless of method of storage, type, or number of guns, these firearms-related variables do appear to modify risk substantially. There is a gradient of risk, with higher odds of association for handguns vs. long guns, loaded guns vs. unloaded guns, and unlocked vs. locked guns (Brent et al., 1993a; Kellermann et al., 1992; See Table 2).

There appears to be some interaction with demographic factors, at least in adolescents, insofar as long guns convey an increased risk to males, but not females, and handguns convey a particularly increased risk for females (Brent et al., 1993a). Furthermore, in adolescents, long guns, but not handguns convey an increased risk in rural areas (OR?s 4.5 vs. 1.0), whereas in urban areas, this situation is reversed, with handguns conveying a much higher risk than long guns (OR?s 5.6 vs. 1.3; Brent et al., 1993a).

In the American studies, guns in the home are associated with suicide in both males and females (Table 3). In fact, firearms are the first choice as a method of suicide for both males and females, notwithstanding females? lower absolute rates. As noted above, handguns are particularly closely associated with suicide in females, whereas long guns are more often used by males (Brent et al., 1993a, 1999). Beautrais et al. (1996) found absolutely no relationship between firearms in the home and suicide in males, with whatever modest association was noted coming from the relatively small female subsample.

In the one study that focused on the entire lifespan, it appears that the association between suicide and firearms in the home is strong across all age groups, but was particularly high in the 24 and younger group (OR?s 10.4 vs. 4.0-7.2 for those 25 and older; Kellermann et al., 1992). In a comparison of risk factors for older (> 16 years) and younger adolescent suicide victims, it was found that younger suicide victims have lower suicidal intent, lower rates of psychopathology in general, and lower rate of substance abuse in specific. The population attributable risk for suicide due to the availability of firearms was actually more substantial than that due to psychopathology in the younger group, whereas this relationship was reversed in the older adolescent group (Brent et al., 1999, see Fig. 3).

This suggests that firearms availability may play a particularly important role in suicidal risk in the young, and that method restriction may therefore be relatively more important in the prevention of younger suicides.

Because the samples reported have been almost entirely Caucasian, the relationship between firearms availability and suicide has not been carefully studied in other ethnic groups. However, the increase in the suicide rate among young African American males is accounted for mostly by an increase in suicide by firearms (CDC, 1994).

In the above-noted community studies, guns in the home convey a 4-5 fold increased risk for suicide, after adjusting for the impact of psychiatric disorder (Brent et al., 1993a, 1999; Kellermann et al., 1992). However, guns in the home appear to convey a particularly increased risk for suicide in those with no apparent psychopathology (See Table 4). Kellermann et al. (1992) reported that guns in the home conveyed a 3-fold elevated risk for suicide in those with psychiatric disorder, but a nearly 33-fold increased risk for completed suicide in those without apparent psychopathology. Similarly, Brent et al (1993a, b) found that a loaded gun in the home conveyed a 32-fold increased risk for suicide in those without apparent psychopathology. These results, which may initially appear counterintuitive, are a consequence of the dramatic increase in risk for impulsive suicide that having a loaded gun in the home conveys even to persons without psychopathology.

One study specifically addressed the ratio of the benefit of having a gun in the home for protection to the risk of suicide and other untoward outcomes. The frequencies of firearms homicides in the home that occurred due to self-protection were compared to the frequency of other types of homicides, accidental deaths, and suicides in metropolitan Seattle (Kellermann &Reay, 1986). For every homicide that occurred out of self-protection, there were 37 suicides, strongly suggesting that there is a high cost for maintaining a gun in the home for the purpose of self-protection.

Gun control legislation, firearms availability and suicide Several approaches have been taken to link differences in gun control legislation and firearms availability to suicide rates. First, there have been cross-sectional comparisons between countries on gun availability and on suicide (Killias, 1993; Sloan et al., 1990). Second, there have been cross-sectional correlational examinations of the relationship between the restrictiveness of gun control laws and suicide rates in the United States. Third, there have been a number of quasi-experimental studies that have examined the impact of gun control legislation on suicide rates.

In general, these three types of studies support an inverse relationship between restrictiveness in firearms legislation and the firearms suicide rate. However, there is also some evidence in some of these studies for method substitution. Also, some of the findings may be attributable to an overall secular trend rather than simply due to the legislation.

In a particularly elegant cross-country comparison, the suicide rates in two quite similar cities, Seattle and Vancouver, were compared, with the assumption that there would be lower suicide rates in Vancouver due to the much more restrictive gun control laws in Canada (Sloan et al., 1990). In fact, the overall suicide rates were quite similar in the two cities, albeit with a higher proportion of firearms suicides in Seattle. However, the suicide rate among 15-24 year olds was 40% higher in Seattle, attributable almost entirely to a 10-fold higher rate of suicide by firearms in that city. Therefore, these results suggest that the greater availability of firearms is particularly deleterious for younger people, consistent with the above-noted case-control studies that have found a higher odds ratio, and greater population attributable risk for suicide due to firearms for younger populations (Brent et al., 1999; Kellermann et al., 1992).

One study has examined the relationship between the overall rate of suicide and the percent of households with a gun in the home in fourteen Western countries, and found a strikingly strong correlation (r = .52; Killias, 1993). While international comparisons are always fraught with difficulties due to variabilities in methods for certification of suicide, these findings do support a relationship between method availability and suicide, and suggest that method substitution does not override the overall impact on suiciderate.

Several studies have examined correlations between different aspects of firearms control legislation, (e.g., the requirement for a waiting period, requirement for licensing, restricted availability based on psychiatric and/or criminal records and the suicide rate) (Boor &Bair, 1990; Lester, 1988; Lester &Murrell, 1986). All of these studies have shown an inverse relationship between the restrictiveness of firearms legislation and the overall suicide rates using American states as the unit of analysis. Although there was some evidence of method substitution, the overall impact on the suicide rate was still favorable. Lester (1988) also noted in one study that the prevalence of gun ownership, rather than strictness of gun control laws per se was the best predictor of overall suicide rates. Boor &Bair (1990) took these statistical analyses further by adjusting for other sociodemographic factors that might differ between states and at the same time might be related to the suicide rate, and still found a significant inverse correlation between the restrictiveness of gun control laws and the overall suicide rate (r?s -.25 to -.48).

Therefore, within the limitations of correlational analyses of ecological data, these results are consistent with the view that greater restrictiveness of firearms legislation is associated with a lower overall suicide rate.

Four studies have examined the impact of changes in firearms legislation upon the suicide rates. Two examined the impact of the same law, but over shorter (Rich et al., 1990) and longer (Carrington &Moyer, 1994) periods of time, respectively. The results of neither study are strongly supportive of the impact of legislation upon the suicide rate. A third study examined the impact of legislation on the suicide rate in Washington, D.C., and was able to document significant change, and compare these trends to those in adjoining areas where no such legislative initiatives had taken place (Loftin et al., 1991). Finally, another study, conducted in Australia, found a positive impact of restrictive gun legislation on the suicide rate, albeit with some evidence of method restriction (Cantor &Slater, 1995).

While these studies, taken collectively, are modestly supportive of a role for greater restrictiveness of gun legislation in the reduction of the suicide rate, they cannot control for other temporal trends, and often do not survey a long enough period of time to document whether these positive trends are maintained. Another limitation is that it is impossible to document the extent to which these laws have been successfully enforced.

Rich et al. (1990) examined the impact of a 1978 law enacted in Canada that made ownership of handguns forbidden, required guns to be either registered or surrendered, and restricted from gun ownership those with either a conviction or psychiatric history related to violence. In examining trends in the province of Ontario, a significant decrease in male firearms suicides was documented, but this decrement was offset by an increase in suicide by jumping. Carrington &Moyer (1994) revisited the impact of this law by extending the period of observation, and excluding the year 1978 from data analyses, and observed a significant reduction in firearms, non-firearms and total suicides. Clearly, the decrease in non-firearms suicides could not be attributable to a change in firearms legislation, and suggests that some other social factors were operating over this period of time to that might account for this decrease. This type of result illustrates the ambiguities of ecological studies.

In the best designed of these quasi-experimental studies, Loftin et al. (1991) examined the relationship between legislation enacted in 1976 in the District of Columbia and subsequent time trends in suicide and homicide. This legislation mandated the registration of all firearms, required that new purchasers meet "fitness" and knowledge of safety standards, and necessitated that owners store guns unloaded and disassembled, with certain occupational exceptions, such as law enforcement. The relatively unique aspect of this study was that changes in the rates of suicide and homicide in the District of Columbia were compared to changes in rates of suicide and homicide in neighboring Maryland and Virginia counties, where no such change in firearms legislation had taken place.

In the District of Columbia, subsequent to the enactment of this legislation, a 23% decline in firearms suicide and a 9% decline in non-firearms suicide was noted. Over the same period of time, in the adjoining Maryland and Virginia counties, a 12% increase in firearms suicide and a 2% decline in non-firearms suicide was observed.

One weakness of all ecological studies is that it is impossible to monitor the extent to which these regulations were enforced, or alternatively, were circumvented. However, one might have expected diffusion of unlawful firearms from neighboring counties into the District of Columbia, which would have diluted the potentially salutary impact of the legislation. The inference of a causal relationship between the change in legislation and the decline in suicide is bolstered by the greater effect on firearms vs. non-firearms suicide and the geographic specificity of this effect.

Method substitution did not occur to any substantial degree, and an overall decline in the suicide rate prevailed. The impact of firearms legislation on suicide was examined in Queensland, Australia (Cantor &Slater, 1995). In this legislation, both current and prospective owners of long guns were required to obtain a license. In addition, and new applicants were required to wait 28 days prior to obtaining their gun ("cooling off period"), and were required to pass a safety test.

The suicide rate by firearms declined among men in metropolitan areas, and in provincial cities, but not in rural areas. This effect was most notable among individuals under the age of 30. However, method substitution occurred in all regions but the provincial cities, where overall suicide rates did decline. Two limitations of the study are the absence of a "control" community where no change in legislation had occurred, and the brevity of the observation (only one year pre- and post-legislation).

Prospective Studies

Wintemute et al. (1999) examined the standardized mortality rates (SMRs) of purchasers of handguns in California, who are registered by state law. In 1991, 238, 292 purchasers of handguns were registered, and the standardized mortality ratios for suicide were examined for the six years after the initial purchase. The SMRs due to suicide were increased for the entire six-year period of observation, although the risk for suicide declined exponentially with the time after the purchase. For example, in the first week, month, and year after the purchase of a handgun, the suicide rates by firearms were elevated, 57-, 30-, and 7-fold over the expected rate, respectively, although even at 6 years after the purchase, the rates were still about double the expected rate (See Figs. 4 and 5).

This effect was observed both across the lifespan, and in both sexes, although it was more pronounced in the young and among women. The latter finding is consistent with women?s more specific utilization of handguns for suicide (Brent et al., 1993a, 1999). The extremely high rate of suicide right after purchase is consistent with the purchase of firearms for the purpose of committing suicide. This appears to be contradictory to Kellermann et al.'s (1992) observation that only around 3% of all suicides are committed with guns purchased within the past 2 weeks. However, the findings in this study only indicate that if a gun is purchased, it is often purchased for the purposes of committing suicide.

However, most of the suicides that occurred among these purchasers occurred some time after the purchase, with the risk for suicide remaining elevated for the entire 6 year period of observation.

Conclusions and Recommendations

The convergent evidence from epidemiological, case-control, quasi-experimental and prospective studies is that there is a relationship between gun availability in the home and completed suicide by firearms. In the United States, firearms are by far the most common method of completed suicide, and the prevalence of firearms suicide is closely correlated with firearms ownership rates in international comparisons (CDC, 1994; Killias, 1993). Case-control studies indicate that firearms are much more likely to be in the homes of suicide completers than controls, and that if a gun is in the home, it is highly likely to be used as the method of suicide (Beautrais et al., 1996; Brent et al., 1988, 1991, 1993a; Kellermann et al., 1992).

Handguns, compared to long guns; loaded guns, compared to unloaded guns; and unlocked guns, compared to locked guns, all are more closely associated with suicide (Brent et al., 1993a; Kellermann et al., 1992). The risk conveyed by the availability of guns may be particularly high among adolescents and young adults (Brent et al., 1999; Kellerman et al., 1992; Sloan et al., 1990). The firearms suicide rate, and in general, the overall suicide rate, are related to the strictness of gun control laws and the prevalence of gun ownership (Boor &Bair, 1990; Killias, 1993; Lester, 1988; Lester &Murrell, 1986).

Quasi-experimental studies suggest that greater restrictiveness in gun control laws are associated with declines in firearms suicide, sometimes without compensatory method substitution (e.g., Loftin et al., 1991). Finally, one prospective study indicates that the risk of suicide among handgun purchasers is markedly elevated especially in the first year after purchase (Wintemute et al., 1999). Therefore, method restriction, either on a case-by-case basis, or via population methods, may substantially reduce the rate of suicide, particularly in the United States, where suicide by firearms is the most common method for both males and females. A "cooling-off" period may avert suicides from those who purchase handguns for the purpose of committing suicide.

With regard to case-based approaches to method restriction, remarkably little is known about the efficacy of standard approaches. For example, only two studies have examined the impact of firearms counseling on the removal of firearms with the parents of youth at risk for suicide. In one study, the parents of suicide attempters were counseled about the danger convey by firearms in the home, and 5/8 either removed the gun, or stored the gun in a more secure manner (Kruesi et al., 1999). In a study of depressed adolescents who entered a randomized psychotherapy clinical trial, only 27% of parents who reported having guns in the home at intake removed the guns on follow-up (Brent et al., submitted).

Therefore, it is unwise to assume that providing recommendations on removal of firearms from the home will automatically result in compliance. One factor that may have led to non-compliance with recommendations in the above-cited study was the insistence that the gun, which may have been held for protection, be removed. A compromise recommendation to improve the security of gun storage might have been more favorably received (Webster et al., 1992). In addition, it is important that the clinician be aware of who owns the gun, since it is often the non-gun-owning parent who brings the child to clinic. This being the case, the non-gun owning parent may underestimate the number, type, and method of storage of firearms in the home, and furthermore, may not be able to persuade the spouse of the need to take action. Furthermore, in the above-noted study, 18% of households who initially had no guns in the home eventually acquired them (Brent et al., submitted).

Therefore, it is vital that all parents of at-risk youth be counseled about firearms, and not just those who happen to have firearms in the home at intake.

One population-based approach may be helpful in which the primary care physician ascertains the presence and method of storage of all firearms and counsels the family accordingly. While firearms counseling has gained acceptance as an important component of health supervision, in reality this often fails to occur (Grossman et al., 1995). Moreover, similar to the above-noted experience with depressed adolescents and their parents, patients surveyed indicate that they are often non-compliant with physician recommendations to secure or remove firearms (Weil &Hemenway, 1992). Nevertheless, because of the findings relating increased risk for suicide to having a loaded gun in the home even in the absence of psychopathology, it is incumbent for the primary care physician to emphasize the risk conveyed by a gun in the home to all children, and not just those who have serious psychiatric illnesses.

Finally, there are population approaches, through legislative initiatives that alter procedures for firearms acquisition and ownership. Cross-sectional and quasi-experimental studies provide modest support for the utility of such approaches for the reduction of firearms suicide in specific, and the overall suicide rate aswell.

References

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Boyd, J.H. (1983). The increasing rate of suicide by firearms. New England Journal of Medicine, 308, 872-874.

Boyd, J.H., &Moscicki, E.K. (1986). Firearms and youth suicide. American Journal of Public Health, 76(10), 1240-1242.

Brent, D.A., Perper, J.A., &Allman, C.J. (1987). Alcohol, firearms, and suicide among youth: Temporal trends in Allegheny County, Pennsylvania, 1960 to 1983. Journal of the American Medical Association, 257, 3369-3372.

Brent, D.A., Perper, J.A., Goldstein, C.E., Kolko, D.J., Allan, M.J., Allman, C.J., &Zelenak, J.P. (1988). Risk factors for adolescent suicide: A comparison of adolescent suicide victims with suicidal inpatients. Archives of General Psychiatry, 45, 581-588.

Brent, D.A., Perper, J.A., Allman, C.J., Moritz, G.M., Wartella, M., &Zelenak, J.P. (1991). The presence and accessibility of firearms in the homes of adolescent suicides: A case-control study. Journal of the American Medical Association, 266, 2989-2995.

Brent, D.A., Perper, J.A., Moritz, G., Baugher, M., Schweers, J., &Roth, C. (1993a). Firearms and adolescent suicide: A community case-control study. American Journal of Diseases of Children, 147, 1066-1071.

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Brent, D.A., Baugher, M., Birmaher, B., Kolko, D., &Bridge, J. (submitted). Compliance with recommendations to remove firearms by families participating in a clinical trial for adolescent depression. Journal of the American Academy of Child and Adolescent Psychiatry.

Cantor, C.H., &Slater, P.J. (1995). The impact of firearm control legislation on suicide in Queensland: Preliminary findings. Medical Journal of Australia, 162, 583-585.

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Rich, C., Young, J., Fowler, R.C., Wagner, J., &Black, N.A. (1990). Guns and suicide: Possible effects of some specific legislation. American Journal of Psychiatry, 147, 342-346.

Rivara, F.P., Mueller, B.A., Somes, G., Mendoza, C.T., Rushforth, N.B., &Kellermann, A.L. (1997). Alcohol and illicit drug abuse and the risk of violent death in the home. Journal of the American Medical Association, 278(7), 569-575.

Sloan, J.H., Rivara, F.P., Reay, D.T., Ferris, J.A.J., &Kellermann, A.L. (1990). Firearm regulations and rates of suicide -- A comparison of two metropolitan areas. New England Journal of Medicine, 322, 369-373.

Webster, D.W., Wilson, M.E.H., Duggan, A.K., Pakula, L.C. (1992) Parent

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