Special report by Madeline Drexler, Editor, Harvard Public Wellness

In the national contend over gun violence—a contend stoked by mass murders such as terminal December'due south tragedy in a Newtown, Connecticut, elementary school—a glaring fact gets obscured: Far more people kill themselves with a firearm each twelvemonth than are murdered with i. In 2010 in the U.S., 19,392 people committed suicide with guns, compared with 11,078 who were killed by others. Co-ordinate to Matthew Miller, associate director of the Harvard Injury Control Research Center (HICRC) at Harvard School of Public Wellness, "If every life is important, and if y'all're trying to relieve people from dying by gunfire, then you lot can't ignore nearly 2-thirds of the people who are dying." Suicide is the 10th-leading cause of death in the U.S.; in 2010, 38,364 people killed themselves. In more than half of these cases, they used firearms. Indeed, more than people in this state kill themselves with guns than with all other intentional means combined, including hanging, poisoning or overdose, jumping, or cutting. Though guns are not the most mutual method by which people attempt suicide, they are the about lethal. Near 85 percent of suicide attempts with a firearm end in death. (Drug overdose, the most widely used method in suicide attempts, is fatal in less than 3 percent of cases.) Moreover, guns are an irreversible solution to what is oft a passing crisis. Suicidal individuals who have pills or inhale car frazzle or use razors have fourth dimension to reconsider their actions or summon assistance. With a firearm, once the trigger is pulled, in that location's no turning back.

Non "Why?" but "How?"

When we think of suicide, we usually think of a drastic act capping years of torment. According to the National Establish of Mental Health, complex and deep-rooted problems—such equally depression and other mental disorders, drug and alcohol abuse, family violence, and a family history of suicide—often shadow victims. Suicide among males is iv times higher than among females. In adults, separation or divorce raises the risk of suicide attempts. In young people, physical or sexual abuse and disruptive behavior increment vulnerability.

The harrowing fact of suicide demands a story: "Why?" But from a public health perspective, an as illuminating question is "How?" Intent matters, but and then does method, because the method past which one attempts suicide has a cracking deal to do with whether i lives or dies. What makes guns the most common mode of suicide in this country? The answer: They are both lethal and accessible. Almost 1 in iii American households contains a gun. The price of this easy access is high. Gun owners and their families are much more probable to impale themselves than are non-gun-owners. A 2008 written report by Miller and David Hemenway, HICRC manager and writer of the book Private Guns, Public Health, institute that rates of firearm suicides in states with the highest rates of gun ownership are iii.7 times higher for men and 7.9 times higher for women, compared with states with the lowest gun ownership—though the rates of not-firearm suicides are virtually the same. A gun in the home raises the suicide risk for anybody: gun owner, spouse and children akin.

This stark connection holds true even when other factors are taken into account. "It was a reasonable hypothesis to remember that the type of person who chooses to own a gun is different from the type of person who chooses not to. Peradventure there's a 'go-it-alone' mental attitude that leads to less help seeking. Or maybe gun owners are more likely to live in rural areas, and rural locales are associated with greater suicidality," explains Catherine Hairdresser, director of HICRC'due south Ways Matter entrada, a suicide prevention effort that focuses on the ways people attempt to take their own lives. "Only when we compared people in gun-owning households to people not in gun-owning households, in that location was no difference in terms of rates of mental illness or in terms of the proportion saying that they had seriously considered suicide," Barber says. "Actually, among gun owners, a smaller proportion say that they had attempted suicide. So it'due south not that gun owners are more suicidal. It's that they're more likely to die in the event that they become suicidal, considering they are using a gun."

While gun-suicide rates are higher in rural states, which have proportionally more gun owners, the gun-suicide link plays out in urban areas, too. "In the early 1990s, the dramatic rise in immature black male suicides was in lock step with the homicide epidemic of those years," says HSPH's Deborah Azrael, associate director of the Harvard Youth Violence Prevention Center. "Young black male suicide rates approached those of immature white males—though black suicide rates had ever been much lower than white suicide rates. It was entirely attributable to an increase in suicide by firearms." Put simply, the fatal link applies across the board. "Information technology'southward true of men, it's true of women, information technology's true of kids. It'south truthful of blacks, it'south truthful of whites," says Azrael. "Cutting it notwithstanding you lot want: In places where exposure to guns is higher, more people die of suicide."Access-to-guns-and-risk-of-suicide-chart

Impulsive Acts

The scientific study of suicide has partly been an attempt to erase myths. Peradventure the biggest fallacy is that suicides are typically long-planned deeds. While this can be true—people who endeavor suicide ofttimes face a cascade of bug—empirical testify suggests that they act in a moment of cursory but heightened vulnerability.

"One of the things that got me interested in launching the Means Affair campaign was that I had been reading through thousands of thumbnail sketches of suicide deaths, to run into if a reporting arrangement we were testing was catching the experience for the example," says Hairdresser. "I started noticing that, jeez, this decease happened the same day that the kid was arguing with his parents, or that the young homo had just broken upwardly with his girlfriend, or that the heart-anile guy had gotten discussion that the divorce papers had come through. That reactivity surprised me, considering I'd always pictured suicide as being a painful, deliberative process, something that was getting worse and worse, escalating until finally y'all've got it all planned out and yous do information technology. Information technology hadn't occurred to me that it could be a cop arguing with his wife, and in the midst of the argument, pulling out his gun and killing himself." This impulsivity was underscored in a 2001 study in Houston of people ages 13 to 34 who had survived a near-lethal suicide attempt. Asked how much time had passed between when they decided to take their lives and when they really made the attempt, a startling 24 percent said less than 5 minutes; 48 percent said less than 20 minutes; 70 percentage said less than one 60 minutes; and 86 percent said less than eight hours. The episodic nature of suicidal feelings is also borne out in the aftermath: ix out of 10 people who attempt suicide and survive exercise not proceed to die by suicide later. Every bit Miller puts it, "If you lot relieve a life in the brusque run, you likely salvage a life in the long run."

Lethal Environments

A central tenet of public health is that environment shapes individual behavior. In the realm of suicide, this truth has played out dramatically in contempo history. When widely used lethal means are made less available or less deadly, suicide rates past that method decline, as exercise suicide rates overall. In Sri Lanka, for example, where pesticides are the leading suicide method, the suicide rate fell by half between 1995 and 2005, after the most highly man-toxic pesticides were restricted. Similarly, in the United kingdom of great britain and northern ireland before the 1950s, domestic gas derived from coal contained x to xx percent carbon monoxide, and poisoning past gas inhalation was the leading ways of suicide. A source of natural gas virtually free of carbon monoxide was introduced in 1958; over time, as carbon monoxide in gas decreased, then did the number of suicides overall—driven by a drop in carbon monoxide suicides, even every bit other methods increased somewhat. Changing the ways by which people endeavour to kill themselves doesn't necessarily ease the suicidal impulse or even the rate of attempts. But it does save lives past reducing the deadliness of those attempts.

Dearth of Data

Though these basic facts are known, there is a striking dearth of research on guns and suicide. In the U.S., government officials don't even accept current data on where household gun buying rates are higher or lower. The only survey big plenty to produce state-level estimates of gun buying was conducted by the federal Behavioral Risk Factor Surveillance System, the world's largest ongoing telephone health survey. The survey asked questions about gun ownership in 2001, 2002 and, for the last time, in 2004. It was HICRC investigators who analyzed this state-level information to show that suicide rates run in tandem with gun ownership rates.

Today, the U.S. Centers for Disease Control and Prevention'south National Violent Death Reporting System, which collects data from constabulary and coroners' reports and death certificates on every suicide and homicide, covers only xviii states. Compare this with the National Highway Traffic Rubber Administration's Fatality Analysis Reporting System, which amasses all-encompassing details within thirty days of every fatal car crash on public roads, from the time and location of the accident to atmospheric condition atmospheric condition to the role of alcohol and drugs. Partly as a upshot of this bureaucratic diligence, the fatality rate from auto crashes has dropped by well-nigh a third over the terminal ii decades. Could the same dedication bring down suicides? Matthew Miller thinks information technology can. "Ameliorate information is a good place to commencement. That way, discussions are grounded in facts rather than distorted by ideology. It tin only help foster social-norm-shifting conversations similar to those that took place around cigarette smoking, condom chugalug use and driving drunk," he says. "I'd like physicians to feel it's their responsibility to tell people about the risks. In that location'due south no reason that yous should accept a chat nearly a cycle helmet or a seat belt, only not firearms." But change as well takes time. "With public health, when you don't take the i-size-fits-all solution, yous chip abroad at the problem," says Barber. Preventing suicides will likely require many approaches, from education and media campaigns to skilled treatment and customs support. Ultimately, the goal is to transcend politics—which is why those who have lost loved ones to gun suicide should have the final word:

Ryan is my baby. I remember once telling him, "If anything happens to you lot, I would end to exist." And that's what it feels like. Information technology'southward a pain similar no other. I would encourage open chat—really talking about it. Preventing simply one person from going through what I went through and volition go through for the rest of my life—that would exist plenty for me.

Wendy Tapp, female parent of 19-year-sometime Ryan Tapp, who shot himself with a handgun in 2011

Politics
& Beyond

Gun violence is i of the most politically divisive issues in the United States–and this contentiousness has played out in government funding of research. In 1993, a written report supported past the U.S. Centers for Disease Control and Prevention (CDC) found that, rather than conferring protection, keeping a gun in the house raises the adventure nigh threefold of being shot by a family fellow member or intimate associate. Enraged past what it has called an "almost vicious sentiment against personal firearms buying," the National Burglarize Association in 1996 successfully lobbied Congress to insert this restriction into the CDC budget: "None of the funds made available … may be used to advocate or promote gun control." It was a pointed prohibition that went far beyond the rule that federal inquiry money cannot exist used for lobbying on any outcome. The brake, which was interpreted broadly past CDC, served every bit a virtual ban on firearms research. Since the mid-1990s, the bureau's gun safe research upkeep has dropped by 96 percent. In 2011, the NRA's official website offered a rationale for its efforts to stifle enquiry: "These junk scientific discipline studies … are designed to provide ammunition for the gun control lobby by advancing the false notion that legal gun ownership is a danger to the public health instead of an inalienable right."

Trusting the messenger

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Kevin LaMarque / Reuters

But according to Matthew Miller, associate director of the Harvard Injury Control Enquiry Center (HICRC), "The public wellness message is neither anti-gun nor pro-gun. It's pro-data. A public wellness approach doesn't look and then much to arraign equally to understand and prevent."

"Like older white men, people with mental health problems, people with family histories of suicide, etc., gun owners are 'our' people," adds the HICRC's Catherine Barber, referring to groups with increased suicide run a risk. "Nosotros can't achieve them with an anti-gun agenda. That'southward like sending an anti-gay grouping to do a suicide prevention campaign in the gay and lesbian community. If you lot don't trust the messenger, yous don't trust the message." The Newtown, Connecticut, massacre, in which the young gunman, Adam Lanza, ended his own life after the elementary school binge, opened another public health line of statement: that preventing suicides may likewise prevent homicides, including the relatively tiny number of mass murders. "Mass homicide is an outrageously hostile acting out," says Miller, "and one tin only imagine that it is deeply continued with a hostility directed at oneself too." Withal for Hairdresser, the public health chat around guns is actually trickier since Newtown, because political positions have grown more than entrenched. Toiling for years on the knotty problem of gun suicide has changed her perspective on gun command. "I'm more than enlightened of the cultural carve up between gun owners and non-gun-owners, specially when they get politicized and think ill of 1 another," she says. "Some gun owners call back guns brand their family safer. A lot of the guys, they love the machinery in guns–it'south the aforementioned as the love for fine woodworking tools. There tin also exist cultural connections, where they learned to shoot from their dad or their uncle. Gun owners and not-gun-owners are both caring, but they view the world differently."

Could new laws forestall gun suicide?

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Tim Shaffer / Reuters

The current political debate swirls around universal background checks and attack weapons bans and magazine limits–policies unlikely to have a measurable touch on suicide. Deborah Azrael, associate managing director of the Harvard Youth Violence Prevention Center, is heartened past a less-trumpeted 1999 Connecticut constabulary, which provides a mechanism for people to contact police when they fear a gun volition be used for damage. Police and prosecutors may obtain warrants to seize firearms from people who appear to be an imminent danger to themselves or others. The individual whose guns are taken has the right to a hearing within two weeks. "There have been hundreds and hundreds of people who have been motivated to phone call the police since the constabulary was put into issue in the late 1990s," says Azrael. "And they're not saying, 'I retrieve my hubby is going to kill me.' They're saying, 'I think my husband is going to impale himself.'"

"The backbone of our convictions"

Azrael worries that in the revived fence on gun violence, suicide will exist eclipsed. She as well laments that public health researchers are often reluctant to spin out the implications of the scientific prove virtually firearms, for fearfulness of being accused of an anti-gun bias. "It's a constraint that most researchers don't operate under. People who do research on lung cancer are immune to draw conclusions nigh smoking. The same with people who do research on environmental exposure to PCBs, or on motor vehicle design issues, or on drug overdoses. There's no national organization pillorying them or actively seeking to defund them." In other words, the frank and open conversation most guns that Americans need to have among themselves besides applies to researchers who want to share their findings with the public. As Azrael sees it, "We need to have the courage of our convictions."

Madeline Drexler is the editor of Harvard Public Health Banner photo: January Stromme / gettyimages.com

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