This diary is part of the Firearm Law and Policy group's ongoing series Guns and Suicide.  Previous installments of the series can be found here, and here.

Suicide is a difficult subject.  The word “suicide” congers up images of death, defeat, weakness, failure, shame, and too many other bitter images.  Most people are uncomfortable speaking about suicide, most people feeling suicidal do not admit it publicly, and most people who have survived the suicide death of a loved one grieve in silence.  A profound public stigma surrounds the topic of suicide.  Because of the negative connotations and silence surrounding suicide, what we know about suicide too often gets obscured by popular myths and misconceptions.  In order to dispel some of the misunderstandings about suicide and to encourage conversations about the facts of suicide, this article will review some of the research and findings about suicide and suicidal behavior, with a focus on the role guns play in suicides in America.

In 2010, 38,364 Americans intentionally took their own lives; for the country as a whole, there were 12.1 suicides per 100,000 persons.  Compared to the suicide rate in other countries, the USA ranks about 30th in the world (suicide rate is the number of suicides per unit population – this allows the comparison of suicides across groups of different sizes): the countries with the highest suicide rates are Greenland, South Korea, and Lithuania (with suicide rates of 108 suicides / 100,000 population, 31.7 / 100,000, and 31.0 / 100,000, respectively)  Of the 38,000 suicides that occurred in the USA in 2010, 78.9% were completed by men, and 21.1% were completed by women (a “completed suicide” is a suicidal act that results in death),  Typically, the suicide rate for men in America is 4 times higher than the suicide rate for women; in 2010 the suicide rate for all men was 19.9 / 100,000, and the suicide rate for all women was 5.2 / 100,000 (data from the Centers for Disease Control (CDC).

In America, the suicide rate varies by age group, with older adults completing more suicides than younger people.  In 2010, the suicide rate for persons age 45-64 was 18.6 suicides per 100,000 population, for persons 85 years and older the suicide rate is 17.6 / 100,000.  The suicide rate for persons below the age of 45 was just about 15 / 100,000, while the suicide rate for persons younger than 24 years is 10.5 / 100,000.  Suicide rates also vary by race and ethnicity: in 2010, the highest suicide rate was among whites (approx. 14 suicides per 100,000 population), the next highest rate was among American Indians (approx. 11 / 100,000), and suicide rates for Blacks, Hispanics, and Asian/Pacific Islanders were all below 6.0 / 100,000 (data from the CDC).

So in America, the people who kill themselves are most commonly older white men.

In 2010, some 478,000 people sought care at hospitals for intentionally self-inflicted injuries.  This number gives us some idea of the number of attempted suicidal acts, but it cannot be taken as an accurate count of attempted suicides (a suicide attempt is an act intended to be lethal that does not kill), because not everyone who intentionally hurts themselves intends for those injuries to be lethal, and some people who make a suicide attempt but do not die do not then seek treatment at a hospital and keep their actions and injuries a secret.  A study of eight US states in 2000 reported an estimated rate of attempted suicides to be 119 attempts / 100,000 population (Spicer RS, 2000).  The CDC estimates that there are 25 attempted suicides for every one completed suicide in America.  In a study of American adults (aged ≥ 18 yrs.), 8.3 million adults (3.7% of the US adult population) admitted to thinking about killing themselves in the previous year; 2.2 million adults (1.0% of the US adult population) admitted to making suicidal plans in the previous year; and 1.0  million adults (0.5% of the US adult population) attempted suicide in the previous year.  In a study of a nationally-representative sample of high-school students, 12.8% of students admitted making a suicide plan in the previous year; and 7.8% of students admitted attempting suicide at least once in the previous year (Crosby AD Suicidal thoughts and behaviors among adults aged > 18 years – United States, 2008-2009.  MMWR Surveillance Summary, 2001; 60(13)).

According to a 2011 CDC study, 1.4 million women and 1.04 million men made suicide plans during the study period (2008-2009), and approximately 600,000 women and 400,000 men made suicide attempts during the study period (Crosby AD Suicidal thoughts and behaviors among adults aged > 18 years – United States, 2008-2009.  MMWR Surveillance Summary, 2001; 60(13)).  So while more men than women kill themselves in the USA, women make more suicide attempts than do men.  

The causes of suicide are varied and complex.  Psychiatric illness and drug and alcohol problems play a major role in suicidal behavior.  In an autopsy study of people who had completed suicide, fully 33% had elevated levels of alcohol in their blood, 23% tested positive for antidepressant medications, and 20% tested positive for opiates (data from the World Health Organization (WHO): Preventing Suiicde: A Resource for Primary Healthcare Workers).  Many people who attempt suicide report experiencing stressful life events, such as loss of a loved one, recent unemployment, or a financial reversal.  Medical science has identified risk factors for a suicide attempt (a risk factor is an event or setting the has been shown to increase the risk or probability of a disorder) – these include psychiatric illness, old age, alcoholism or substance dependency, a prior history of a suicide attempt, violence in the household, access to firearms, and in children, physical or sexual abuse.(Cheng AT, 2000; Conwell Y, 2002; Beautrais AL, 2002)

Treatment for suicidal ideation (suicidal ideation is repeatedly thinking about killing oneself) and suicidal behavior may consist of psychotropic medications and/or psychotherapy.  For people who pose a high risk for suicide, hospitalization helps to secure the individual in a safe environment - free of common dangers and where they can be closely watched.  Treatment for suicidal ideation and suicidal behavior has been shown in controlled clinical trials to reduce suicidal attempts (Brown GK, 2005; Hawton K, 1998).  Educating physicians and care-givers to recognize and treat depression and other psychiatric conditions is an important strategy to prevent and reduce the incidence of death from suicide (Mann JJ, 2005)

Treatment for suicide works.  Nine out of ten people who survive a suicide attempt will NOT go on to die by suicide at a later date.  In a meta-analysis of over 90 studies, only 7% of people who made a suicide attempt that resulted in medical care eventually died by suicide, 23% tried again to kill themselves but did not succeed, and over 70% did not try suicide again (Owens D, Horrocks J, and House A. Fatal and non-fatal repetition of self-harm: systematic review. British Journal of Psychiatry. 2002;181:193-199).

Is suicide on your mind?  Would you like to talk to someone about suicide? The National Suicide Prevention Lifeline (1-800-273-TALK)(1-800-273-8255) is open 7 days a week, around the clock.  If you are thinking about suicide, or wondering how you can help a friend, or grieving a suicide death of a loved one, the Lifeline is available to you, free of charge.

With this information as background, we can address some of the more common and pervasive confusions and /or myths about guns and suicide with some facts.  

Most gun deaths in America are suicide deaths.
Most gun deaths in America are the result of an intentional self-inflicted shooting, not the act of a violent criminal, or a law-abiding citizen resisting a criminal attack.  In 2010, the last year for which complete records are available, 31, 672 people died from a gunshot injury.  Suicides accounted for 19,392 (61%) of these gunshot deaths.  The other 39% of fatal gunshot injuries were a combination of homicides, defensive shootings, unintentional shootings, and police shootings.  In a study done in and around Seattle, Wash. in the 1980's, for every death resulting from a defensive gun use, there were 1.3 accidental gun deaths, 4.6 criminal shooting deaths, and 37 gun suicides (Kellermann AL, Reay DT. Protection or peril? An analysis of firearm related deaths in the home. N Engl J Med. 1986;314:1557–1560).  In a more recent and larger study of Memphis, Seattle, and Galveston, a gun in the home was 4 times more likely to be involved in an accidental shooting, 7 times more likely to be used in a criminal shooting, and 11 times more likely to be used in a suicide attempt, than to be used in a self-defense shooting (Kellermann AL, Somes G, Rivara FP, Lee RK, Banton JG. Injuries and deaths due to firearms in the home. J Trauma. 1998;42:263–267).  Far and away more guns deaths are self-inflicted than the result of both criminal and self-defensive shootings.

The risk of dying from a suicide attempt is greatest when a gun is used
This table comes from the Harvard School of Public Health.  This table shows the number of US suicide deaths and visits to hospital ERs for non-fatal self-inflicted injury in 2001.  

Table 1: Frequency and relative lethality of different suicide methods

Method Total* Non-Fatal* Fatal* % Fatal
Firearms 19,894 2,980 16,869 84.8%
Suffocation1 8,959 2,761 6,198 69.2%
Falls 2,085 1,434 651 31.2%
Poisoning2 221,005 215,814 5,191 2.3%
Cutting/Stabbing 63,275 62,817 458 0.7%
Other 36,198 35,089 1,109 3.1%
Unspecified 2,243 2,097 146 6.5%
Totals 353,613 322,991 30,622 8.7%
The total number of suicide attempts, number of non-fatal suicide attempts, number of fatal suicide attempts, and the percentage of fatal suicide attempts for each suicide method.  Data for the entire US, for the year 2001.
* number of cases
1 - includes Hangings
2 - includes Drug Overdoses
From the table we can see that the vast majority of suicide attempts (in America) are not fatal, and that the most common methods for attempting suicide are Poisonings/Overdoses and Cutting/Stabbing.  However, the most lethal suicide method is firearms, which results in death 85% of the time.

In suicide, the method one chooses has a lot to do with whether one lives or dies.  In a study of suicide attempts occurring in Illinois from 1990 to 1997, persons who used a gun to attempt suicide were 2.6 times more likely to die than persons attempting suicide by suffocation or hangings (the second-most lethal suicide method) (Shenassa ED, 2003).  

Suicide is more likely to occur when a gun is available
Gun-owners and their family members are much more likely to kill themselves than are non gun-owners.  In a study of completed suicides and gun ownership, there was a strong positive correlation of the number of suicides in a state with the states' rates of gun ownership, even after controlling for suicide attempts (Miller & Hemenway D. 2008; Miller M. 2013).  The positive association of gun ownership and suicide remained true after controlling for suicidal ideation and psychiatric disorders as well (Miller M. 2009).  And in a study that compared 86 adults aged 50 and older who completed suicide and control subjects (matched for age, sex, race, and county of residence) the presence of a firearm in the home was associated with an increased risk of suicide, even after controlling for psychiatric illness (Conwell Y, 2002).  In another study of US mortality data, the risk of dying by suicide for men with a gun in the home was 10.4 times greater than the risk of dying by suicide for men who live in a home where there is no gun.  Persons (men and women) who lived in a home where there was a gun were 31.1 times more likely to die by gun suicide than persons who lived in a home where there was no gun.  Persons who lived in a home where there was a gun have a 1.9 times greater risk of dying by homicide in the home than people living in a home where there is no gun.  (Dahlberg LL, 2004).  This finding that the risk of suicide is greater for those who have a gun has been replicated repeatedly using a variety of different methods. (Cummings P, 1997; Miller M, 2008; Ajdacic-Gross V, 2008)

Reducing the availability of guns reduces suicide deaths

In recent years, both the number of guns and the number of gun suicides have been increasing in the US, and studies show a strong positive correlation between the two (Bissell HJ, 2013).  The strong association of gun availability and gun suicides indicates that we can expect gun suicides to continue to rise as the number of guns in the country increases, and we can also expect a reduction in the number of guns suicides should the number of guns available in the USA ever decrease.

Two western, industrialized, multicultural countries – similar to the USA – placed severe limitations on the availability of guns among the general population, providing researchers an opportunity to see how the implementation of such laws might change the incidence of gun suicides.  In 1996, Australia passed new gun control laws to outlaw shotguns and semi-automatic rifles, along with new licensing, registration, and storage requirements.  In a study that examined rates of gun deaths before and after the passing of the gun control measures, there were statistically significant reductions in mass shootings, total firearm deaths, firearm suicides, and firearm homicides.  (Chapman S, 2006).  Another study reported a reduction in firearm suicides only (Baker J, 2007)

In 1977, Canada passed Bill C-51, increasing the regulations on acquiring guns and introduced controls on ammunition sales.  An analysis of the suicide data showed decreases in the rate of gun suicides and the percentages of suicides using a gun after passage of the law (Lester D, 1993; Leenaars AA, 2003).  A second piece of legislation – Bill C-17, passed in 1991 to restrict sales of some guns and adding new licensing requirements – has also been shown to have reduced both firearm suicides and homicides (Bridges FS, 2004).

Here in the USA, we know that restricting access to firearms reduces both suicide attempts and deaths from suicides by virtue of the routine admission of severely suicidal people to psychiatric facilities where guns are not available to the patients who are thinking of killing themselves.

Some popular myths about suicide.

Myth 1: Suicidal people are absolutely intent on dying.

It is part of our biologically-inborn human nature to live and to go on living.  Researchers had long ago identified ambivalence as a core feature of a suicidal crisis (a “suicidal crisis” is the name given for that period of time when a person is actively making plans to kill themselves) (Shneidman, E.S. A conspectus of the suicidal scenario. In R.W. Maris, A.L. Berman, J.T. Maltsberger, & R. I. Yufit (Eds.), Assessment and prediction of suicide (pp. 50-64). Guilford Press, New York.1992) (Cardell, R., & Horton-Deutsch, S. A model for assessment of inpatient suicide potential. Archives of Psychiatric Nursing. 1994; 8:366-372) (WHO).   Most people who are thinking about killing themselves are highly ambivalent about this course of action, and spend as much time thinking about living as they do thinking about killing themselves.  In this highly liable emotional state, the suicidal person is easily influenced.  Insignificant events are given out-sized import (“if the phone doesn't ring in the next five minutes, that means I should kill myself.”).  However, this ambivalence gives clinicians and care-givers opportunities to intervene and present alternatives to the suicidal act.  This is one reason why the New York State Bridge Authority installed phones linking to the National Suicide Prevention Lifeline on bridges around New York City and across the Hudson River.

Myth 2: Suicide happens without warning.
Most people who kill themselves provide many indications of their suicidal thinking.  Those signs can be verbal (expressions of feelings of hopelessness or worthlessness, talking about hurt, loss, death in general or suicide in particular,), and behavioral (changes in personality, withdrawing from friends and family, increasing alcohol or substance use, a sudden desire to write a will or tidy up personal affairs).  Admittedly, these signs may be subtle and easily overlooked, and too often only become clear after a suicidal act has been made.

Myth 3: Once a person is suicidal, they will then always be suicidal
Most people turn to suicide during a personal crisis or after a loss.  The vast majority of people who come through these crises without killing themselves will never die by suicide.  For some people, once the crisis has passed, the suicidal thoughts may return but the pressing need to act on those thoughts does not.  And for some people, the suicidal thinking does not return at all.  Very few people are suicidal on a permanent basis.

Nine out of ten people who survive a suicide attempt will NOT go on to die by suicide at a later date.  In a meta-analysis of over 90 studies, only 7% of people who made suicide attempts that resulted in medical care eventually died by suicide, 23% tried again to kill themselves but did not succeed, and over 70% never made repeat suicide attempts (Owens D, Horrocks J, and House A. Fatal and non-fatal repetition of self-harm: systematic review. British Journal of Psychiatry. 2002;181:193-199).

Myth 4: People have a right to choose to die
There is a good deal of controversy over legal and ethical arguments about an individual's entitlement or right to kill themselves versus the states' interest in maintaining a living populace.  It should be pointed out that the vast majority of people who are thinking about suicide are not in a good frame of mind to be making such a momentous decision: most are not making a mindful or rational choice.  The fact is that most people who kill themselves have either a psychiatric disorder or are drinking and/or using drugs.  In an autopsy study of people who have completed suicide, fully 33% had elevated levels of alcohol in their blood, 23% test positive for antidepressant medications, and 20% tested positive for opiates (WHO).  And many people contemplating suicide are experiencing painful and stressful life events (recent bereavement or divorce, loss of a job, etc).  Psychiatric illness, alcohol and drug use, and stress are all know to impair cognition and judgment.  It is highly likely that someone considering suicide is not doing their best thinking, and is not in a position to make a rational choice about their death.  

There are people who find themselves with a painful and terminal illness without hope of useful medical intervention, for whom suicide or voluntary euthanasia may be a rational choice.  For such people, perhaps a good measure of that person's ability to think soundly and rationally about their desire to kill themselves is their willingness to talk openly about their thinking with a doctor and with their family members and loved one, and to include the concerns of their loved ones in their own plans.  

Myth 5: You can't stop someone who wants to die; they will find a way to kill themselves
It is true that you cannot prevent ALL suicides, and it is equally true that suicide is preventable.  Putting tall fences on high bridges stops people from killing themselves.  Removing guns, knives, and dangerous medications from suicidal people stops people from killing themselves.  When suicidal people are barred from access to lethal suicide means and then choose less lethal suicide means or simply postpone their attempt for a period of time, their risk of dying is reduced, and the result is fewer deaths (Harvard School of Public Health: Means Matter).  Treatment for suicidal behavior is effective: the vast majority of people who act suicidally and get treatment do not end up dying of suicide – the treatment works.

Myth 6: Suicide is painless.
We do not actually know if suicide is painless: no one has ever come back after a completed suicide to tell us whether suicide is painless or not.  It is very clear that people experience a great deal of pain leading up to the suicidal act.  It is also very clear that those who survive the suicidal death of a loved one experience a profound and prolonged period of pain.  

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Originally posted to Firearms Law and Policy on Mon Nov 18, 2013 at 11:40 AM PST.

Also republished by Shut Down the NRA.

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