Special report by Madeline Drexler, Editor, Harvard Public Health

In the national debate over gun violence—a debate stoked by mass murders such as last Dec's tragedy in a Newtown, Connecticut, unproblematic school—a glaring fact gets obscured: Far more people kill themselves with a firearm each twelvemonth than are murdered with one. In 2010 in the U.S., xix,392 people committed suicide with guns, compared with xi,078 who were killed past others. According to Matthew Miller, acquaintance director of the Harvard Injury Control Enquiry Middle (HICRC) at Harvard School of Public Wellness, "If every life is important, and if you're trying to save people from dying by gunfire, then you can't ignore nearly ii-thirds of the people who are dying." Suicide is the 10th-leading crusade of death in the U.S.; in 2010, 38,364 people killed themselves. In more than one-half of these cases, they used firearms. Indeed, more people in this country kill themselves with guns than with all other intentional means combined, including hanging, poisoning or overdose, jumping, or cut. Though guns are not the most mutual method past which people attempt suicide, they are the most lethal. About 85 percent of suicide attempts with a firearm terminate in death. (Drug overdose, the most widely used method in suicide attempts, is fatal in less than 3 per centum of cases.) Moreover, guns are an irreversible solution to what is oft a passing crisis. Suicidal individuals who accept pills or inhale automobile frazzle or use razors accept time to reconsider their actions or summon help. With a firearm, one time the trigger is pulled, in that location's no turning back.

Not "Why?" just "How?"

When we think of suicide, we usually call up of a drastic act capping years of torment. According to the National Institute of Mental Health, circuitous and deep-rooted problems—such as low and other mental disorders, drug and alcohol abuse, family unit violence, and a family unit history of suicide—often shadow victims. Suicide among males is four times college 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?" Only from a public health perspective, an every bit illuminating question is "How?" Intent matters, but and then does method, because the method by which one attempts suicide has a smashing deal to do with whether one lives or dies. What makes guns the most common mode of suicide in this country? The answer: They are both lethal and attainable. About 1 in three American households contains a gun. The price of this piece of cake access is high. Gun owners and their families are much more likely to kill themselves than are not-gun-owners. A 2008 study by Miller and David Hemenway, HICRC director and author of the book Private Guns, Public Health, plant that rates of firearm suicides in states with the highest rates of gun ownership are 3.vii times higher for men and vii.9 times higher for women, compared with states with the everyman gun ownership—though the rates of not-firearm suicides are about the same. A gun in the home raises the suicide gamble for everyone: gun possessor, spouse and children akin.

This stark connexion holds true fifty-fifty when other factors are taken into account. "Information technology was a reasonable hypothesis to think that the type of person who chooses to ain a gun is dissimilar from the type of person who chooses non to. Maybe there'due south a 'get-it-alone' attitude that leads to less help seeking. Or maybe gun owners are more likely to alive in rural areas, and rural locales are associated with greater suicidality," explains Catherine Barber, director of HICRC's Ways Matter campaign, a suicide prevention endeavor that focuses on the ways people effort to take their own lives. "Only when nosotros compared people in gun-owning households to people non in gun-owning households, there 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 information technology's not that gun owners are more suicidal. Information technology'due south that they're more likely to die in the outcome that they become suicidal, because they are using a gun."

While gun-suicide rates are higher in rural states, which have proportionally more than gun owners, the gun-suicide link plays out in urban areas, as well. "In the early 1990s, the dramatic rise in young blackness 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 blackness male suicide rates approached those of young white males—though black suicide rates had always been much lower than white suicide rates. It was entirely attributable to an increment in suicide by firearms." Put simply, the fatal link applies across the board. "Information technology's truthful of men, it's true of women, it's truthful of kids. It's truthful of blacks, it's true of whites," says Azrael. "Cut it even so y'all 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 effort to erase myths. Perhaps the biggest fallacy is that suicides are typically long-planned deeds. While this tin can be true—people who try suicide oft confront a cascade of problems—empirical evidence suggests that they act in a moment of brief simply 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 see if a reporting organisation we were testing was catching the experience for the case," says Barber. "I started noticing that, jeez, this death happened the same mean solar day that the kid was arguing with his parents, or that the beau had just cleaved up with his girlfriend, or that the middle-aged guy had gotten word that the divorce papers had come through. That reactivity surprised me, because I'd e'er pictured suicide equally existence a painful, deliberative procedure, something that was getting worse and worse, escalating until finally yous've got it all planned out and you lot exercise it. It hadn't occurred to me that information technology 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 written report in Houston of people ages 13 to 34 who had survived a about-lethal suicide attempt. Asked how much time had passed between when they decided to accept their lives and when they actually made the attempt, a startling 24 pct said less than 5 minutes; 48 percentage said less than twenty minutes; seventy percent said less than 1 hour; and 86 percent said less than viii hours. The episodic nature of suicidal feelings is likewise borne out in the backwash: 9 out of 10 people who attempt suicide and survive do not go on to dice by suicide later. As Miller puts it, "If yous save a life in the short run, yous likely salve a life in the long run."

Lethal Environments

A central tenet of public health is that environment shapes private behavior. In the realm of suicide, this truth has played out dramatically in recent history. When widely used lethal means are made less bachelor or less mortiferous, suicide rates past that method decline, as do suicide rates overall. In Sri Lanka, for instance, where pesticides are the leading suicide method, the suicide rate fell by half betwixt 1995 and 2005, after the most highly human-toxic pesticides were restricted. Similarly, in the United kingdom before the 1950s, domestic gas derived from coal independent x to twenty percent carbon monoxide, and poisoning by gas inhalation was the leading means 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 driblet in carbon monoxide suicides, even as other methods increased somewhat. Changing the means by which people try to kill themselves doesn't necessarily ease the suicidal impulse or even the charge per unit of attempts. Just it does relieve lives past reducing the deadliness of those attempts.

Dearth of Information

Though these bones facts are known, there is a hitting dearth of enquiry on guns and suicide. In the U.S., authorities officials don't even have current data on where household gun buying rates are higher or lower. The only survey large enough to produce state-level estimates of gun buying was conducted by the federal Behavioral Risk Factor Surveillance System, the world'due south largest ongoing telephone wellness survey. The survey asked questions about gun ownership in 2001, 2002 and, for the terminal time, in 2004. It was HICRC investigators who analyzed this country-level information to prove that suicide rates run in tandem with gun buying rates.

Today, the U.S. Centers for Affliction Control and Prevention'due south National Violent Death Reporting System, which collects data from police and coroners' reports and death certificates on every suicide and homicide, covers only eighteen states. Compare this with the National Highway Traffic Safety Administration's Fatality Analysis Reporting Arrangement, which amasses all-encompassing details within 30 days of every fatal car crash on public roads, from the time and location of the accident to weather conditions to the part of alcohol and drugs. Partly every bit a consequence of this bureaucratic diligence, the fatality rate from motorcar crashes has dropped past most a 3rd over the final two decades. Could the same dedication bring down suicides? Matthew Miller thinks it can. "Amend information is a good identify to start. That fashion, discussions are grounded in facts rather than distorted by ideology. It tin can only help foster social-norm-shifting conversations similar to those that took place around cigarette smoking, prophylactic belt employ and driving drunk," he says. "I'd similar physicians to experience it'due south their responsibleness to tell people about the risks. At that place's no reason that you should take a conversation about a cycle helmet or a seat belt, but not firearms." But change also takes time. "With public wellness, when you don't accept the i-size-fits-all solution, you chip away at the trouble," says Hairdresser. Preventing suicides will probable require many approaches, from education and media campaigns to skilled treatment and community 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 annihilation happens to y'all, I would cease to be." And that's what it feels like. It'due south a pain like no other. I would encourage open up chat—actually talking almost information technology. Preventing just one person from going through what I went through and will go through for the rest of my life—that would be enough for me.

Wendy Tapp, mother of 19-year-old Ryan Tapp, who shot himself with a handgun in 2011

Politics
& Beyond

Gun violence is 1 of the nigh politically divisive bug in the United states of america–and this contentiousness has played out in regime funding of research. In 1993, a report supported by the U.S. Centers for Affliction Command and Prevention (CDC) found that, rather than conferring protection, keeping a gun in the firm raises the risk well-nigh threefold of being shot past a family member or intimate associate. Enraged past what information technology has called an "most fell sentiment confronting personal firearms buying," the National Rifle Association in 1996 successfully lobbied Congress to insert this brake into the CDC upkeep: "None of the funds made bachelor … may be used to abet or promote gun control." Information technology was a pointed prohibition that went far beyond the rule that federal research coin cannot be used for lobbying on whatever consequence. The brake, which was interpreted broadly by CDC, served as a virtual ban on firearms research. Since the mid-1990s, the bureau'south gun safety research budget has dropped by 96 pct. In 2011, the NRA'due south official website offered a rationale for its efforts to stifle research: "These junk science studies … are designed to provide ammunition for the gun control lobby past advancing the simulated notion that legal gun buying is a danger to the public health instead of an inalienable right."

Trusting the messenger

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Kevin LaMarque / Reuters

Only co-ordinate to Matthew Miller, associate manager of the Harvard Injury Control Enquiry Middle (HICRC), "The public health message is neither anti-gun nor pro-gun. It's pro-information. A public health approach doesn't expect and then much to blame as to understand and prevent."

"Similar 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 Hairdresser, referring to groups with increased suicide take chances. "We can't reach them with an anti-gun calendar. That'south similar sending an anti-gay group to do a suicide prevention campaign in the gay and lesbian community. If you don't trust the messenger, you don't trust the message." The Newtown, Connecticut, massacre, in which the immature gunman, Adam Lanza, ended his own life later the elementary schoolhouse rampage, opened another public health line of argument: that preventing suicides may also preclude homicides, including the relatively tiny number of mass murders. "Mass homicide is an outrageously hostile interim out," says Miller, "and ane can only imagine that it is deeply connected with a hostility directed at oneself too." Withal for Barber, the public wellness conversation around guns is actually trickier since Newtown, because political positions have grown more entrenched. Toiling for years on the knotty problem of gun suicide has changed her perspective on gun control. "I'm more aware of the cultural divide between gun owners and non-gun-owners, especially when they become politicized and call back ill of one another," she says. "Some gun owners think guns make their family safer. A lot of the guys, they love the mechanism in guns–it's the same every bit 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 non-gun-owners are both caring, but they view the world differently."

Could new laws prevent gun suicide?

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Tim Shaffer / Reuters

The electric current political debate swirls around universal background checks and attack weapons bans and magazine limits–policies unlikely to have a measurable impact on suicide. Deborah Azrael, acquaintance director of the Harvard Youth Violence Prevention Middle, is heartened by a less-trumpeted 1999 Connecticut law, which provides a machinery for people to contact constabulary when they fear a gun volition be used for harm. Police and prosecutors may obtain warrants to seize firearms from people who announced to be an imminent danger to themselves or others. The individual whose guns are taken has the correct to a hearing within 2 weeks. "In that location have been hundreds and hundreds of people who have been motivated to call the police force since the law was put into effect in the tardily 1990s," says Azrael. "And they're non proverb, 'I think my husband is going to kill me.' They're saying, 'I remember my married man is going to kill himself.'"

"The courage of our convictions"

Azrael worries that in the revived debate on gun violence, suicide will be eclipsed. She besides laments that public health researchers are oft reluctant to spin out the implications of the scientific prove nigh firearms, for fearfulness of being accused of an anti-gun bias. "It's a constraint that near researchers don't operate under. People who exercise research on lung cancer are immune to describe conclusions nearly smoking. The aforementioned with people who do research on environmental exposure to PCBs, or on motor vehicle blueprint issues, or on drug overdoses. There'southward no national organization pillorying them or actively seeking to defund them." In other words, the frank and open chat nigh guns that Americans demand to have amid themselves likewise applies to researchers who want to share their findings with the public. Equally Azrael sees information technology, "We need to take the backbone of our convictions."

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

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