Suicide,Guns, and Public Policy

Suicide is a serious public health concern that is responsible for almost 1 million deaths each year worldwide. It is commonly an impulsive act by a vulnerable individual. The impulsivity of suicide provides opportunities to reduce the risk of suicide by restricting access to lethal means.In the United States, firearms, particularly handguns, are the most common means of suicide. Despite strong empirical evidence that restriction of access to firearms reduces suicides, access to firearms in the United States is generally subject to few restrictions.Implementation and evaluation of measures such as waiting periods and permit requirements that restrict access to handguns should be a top priority for reducing deaths from impulsive suicide in the United States.

“Knowing is not enough; we must apply. Willing is not enough; we must do.”1a

—Johann Wolfgang von Goethe

Suicide is a complex behavior involving the intentional termination of one’s own life. The prevalence, causes, means, and prevention of suicide have been extensively studied and widely reported.1b–4 The World Health Organization (WHO) has identified suicide as a serious public health concern that is responsible for more deaths worldwide each year than homicide and war combined,5 with almost 1 million suicides now occurring annually. In 2007, the Centers for Disease Control and Prevention (CDC) reported that 34 598 Americans died by suicide, far more than the 18 361 murders during the same period.6 Among Americans younger than 40 years, suicide claimed more lives (n = 13 315) than any other single cause except motor vehicle accidents (n = 23 471).6Psychiatric disorders are present in at least 90% of suicide victims, but untreated in more than 80% of these at the time of death.7 Treatment of depression and other mood disorders is therefore a central component of suicide prevention. Other factors associated with suicidal behavior include physical illness, alcohol and drug abuse, access to lethal means, and impulsivity. All of these are potentially amenable to modification or treatment if recognized and addressed. It is important to distinguish between impulsivity as a personality trait and the impulsivity of the act of suicide itself. It is not generally appreciated that suicide is often an impulsive final act by a vulnerable individual8 who may or may not exhibit the features of an impulsive personality.9The impulsivity of suicide provides opportunities to reduce suicide risk by restriction of access to lethal means of suicide (“means restriction”). Numerous medical organizations and governmental agencies, including the WHO,5 the European Union,10 the Department of Health in England,11 the American College of Physicians,12 the CDC,4,13 and the Institute of Medicine,14 have recommended that means restriction be included in suicide prevention strategies. In the United States, firearms are the most common means of suicide,15 with a suicide attempt with a firearm more likely to be fatal than most other means.16 In a study of case fatality rates in the northeastern United States, it was found that 91% of suicide attempts by firearms resulted in death.17 By comparison, the mortality rate was 84% by drowning and 82% by hanging; poisoning with drugs accounted for 74% of acts but only 14% of fatalities. Many studies have shown that the vast majority of those who survive a suicide attempt do not go on to die by suicide. A systematic review of 90 studies following patients after an event of self-harm found that only two pecent went on to die by suicide in the following year and that seven percent had died by suicide after more than nine years.18The availability of guns in the community is an important determinate of suicide attempts by gun.19 Given the public health importance of suicide and what is known about the role of guns in suicide, strategies that keep guns out of the hands of individuals who intend self-harm are worthy of careful scrutiny. Since a handgun (revolver or pistol) is far more likely to be used for suicide than a long gun (shotgun or rifle),20 it may be particularly beneficial to focus suicide prevention efforts on this type of weapon. Only a small minority of states restrict access to handguns by methods such a waiting period, a permit requiring gun safety training, or safe storage of guns in the home. In 2010, US Department of Justice reported that only 15 states had a waiting period for purchasing a handgun.21 Although federal law prohibits the sale of handguns to persons younger than 21 years, in the absence of federal preemption (i.e., the removal of legislative authority from a lower level of government), some states and municipalities allow the sale of handguns to younger individuals.21     

Navigating Children (NI) Order 1995 Applications through the Courts: Revised Best Practice Guidance

This article considers the launch of the Revised Best Practice Guidance 2010 by the Children Order Advisory Committee. The original guidance was launched in 2003 and the revised guidance reflects the changes in policies and practices over the past seven years.     

Home Care for Ventilator-Assisted Children: Implications for the Children, Their Families, and Health Policy

This article presents findings from a national study of home care programs for ventilatorassisted children conducted between 1984 and 1987 by the Center for Health Administration Studies at The University of Chicago These findings point to the issues that need to be addressed in the development of policies surrounding both the delivery and the financing of services for these children and their families (a) ventilator-assisted children are a widely varying group with diverse needs, (b) most families report that though they are glad to bring their child home, many difficult adjustments are required to do so, (c) full-time nursing care offers support to families but also intrudes on their privacy, (d) both families and children need social and psychological support once the child is home, (e) the needs of the child and the family may change over time, and (f) the financial burden of having a child on a ventilator at home can be a big stress on the family.     

The Moving Children Project: A Conceptual, Process-Oriented Model for Skills Development in Children

The Moving Children: Healthy Children (Moving Children) Project is a multidimensional conceptual model that provides elementary teachers a structure to incorporate mental and social concepts into a physical education program. The Moving Children Model focuses on four physical concepts which cover the full range of physical activity: body movement, object control, implement control, and game structure. The model helps children apply physical, mental, and social concepts to everyday situations. This objective is implemented by structuring the lesson to the environment and facilitating communication with follow-up classroom dialogue and journal assignments. As a result, successful, experimental learning reinforces a life-long attachment to movement and principles of health promotion.     

Courts uphold HIV test for rapist, but not for child molester

Mandatory HIV testing of convicted sex offenders can be ordered by trial judges. In two separate California appeals court cases, the judges reached opposite conclusions regarding this testing. One court upheld the mandatory testing of a man convicted of rape. In another California case, regarding a convicted child molester, the court overturned the order to submit to mandatory testing. The appeals court said that the jury had not provided enough information to determine whether or not testing was justified.     

Preventive Interventions for Children of Divorce: A Developmental Model for 5 and 6 Year Old Children

Implemented and evaluated a preventive intervention for kindergarten and first grade children of divorce. Structure and content of the 12 session Children of Divorce Intervention Program (CODIP) was tailored to the developmental characteristics of 5 and 6 year olds. Pre-post comparisons of demographically matched groups of 37 CODIP participants, 26 non-program divorce controls and 39 children from non-divorced families yielded improvements for the experimental group on teacher, parent, child and group leader measures of adjustment. Limitations of the study and directions for future research, including a follow up study, are discussed.     

The Effect of State Gun Laws on the Supply of Guns and Gun Crimes: A Multilevel Modeling Analysis

Gun homicides alone cause 11 000 deaths each year. Numerous shootings in recent years, terrorist and otherwise, have sparked heated debates about gun control policy, particularly with regard to Second Amendment issues. Such discussions are more often than not driven by political and philosophical ideology, rather than empirical data. The self-imposed ban on the dissemination of gun-related statistics on the part of the Centers for Disease Control has created difficulty in obtaining data, particularly at the sub-state level. Furthermore, the majority of previous research has not examined the effect on crimes that are gun specific, that is, homicides or robberies committed using guns versus all homicides or robberies. The objective of this research is to examine the multiple relationships between gun ownership and gun crimes at the sub-state level and to then examine the effect of state-level gun laws on the sub-state relationships via multilevel modeling. This research involves two separate units of analysis, counties and states. Initial multivariate regression was conducted on a subset of counties in the United States examining the relationship between the percentage of all households with at least one gun, and both the gun homicide rate as well as the gun robbery rate. Data on gun ownership were obtained from the CDC's BRFSS SMART County-level data files from the mid-2000s. These data are sampled and weighted to be representative of the entire county. A total of 218 weighted, aggregated counties were used from two separate non-overlapping years combined. Gun crime data were obtained from the FBI Uniform Crime Reports, which provides total universe data on crimes, including the number committed with a gun. State gun law rankings were obtained from the Law Center to Prevent Gun Violence, which quantifies state gun laws into a numeric index. Standard county-level control variables such as race, income, poverty, region of the country, level of education, and population density were employed. Multilevel models were then run overlaying state gun laws with county-level data. The population studied included adults age 18 and older who responded to the Centers for Disease Control's BRFSS survey questions, as well as all gun crimes known to the police. In traditional multivariate analysis, a higher percentage of households with guns was associated with lower gun robbery rates as well as lower gun homicide rates. Multilevel modeling using state gun laws indicated that more restrictive gun laws were also associated with lower gun robbery and homicide rates. The percentage of households with guns remained negative and significant in the multilevel models. Moreover, restrictive state gun laws were associated with lower gun ownership rates at the county level. Both legal gun ownership and more restrictive state gun laws are associated with lower rates of violent gun crimes (robbery and homicide). The results unexpectedly provide support for both pro- and anti-gun positions. This suggests that causal patterns are more complex than either position might indicate, and public health policies on gun supply and restriction would be better informed by empirical analysis.