Gun suicides: America's unseen public health crisis

Gun suicides: America's unseen public health crisis
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The numbers confirm what we already know: We’re facing an increasing epidemic of gun deaths in America. 2017 was the most dangerous year yet: U.S. firearm deaths reached 39,773, their highest level in 40 years, increasing 16 percent from 2014. The overall number of gun deaths is often in the news, but the stark surprise for many will be that 60 percent of those nearly 40,000 gun deaths were suicides, 23,854. 

Though suicides are America’s largest firearm-related, public health problem, they’re not the most chronicled. That distinction belongs to homicides, which represented 36.5 percent (14,542) of total gun deaths. Accidental firearm discharges, shooting by law enforcement and mass shootings making up the remainder.

Tragically, our gun suicide rate is 10 times that of other high-income countries, and while we account for about 4 percent of the world’s population, we have 35 percent of the world’s gun suicides. Guns are used in 51 percent of American suicide deaths and suicide rates are higher in states with higher per-capita rates of gun ownership. Most suicide attempts are impulse driven in crises. In 90 percent of suicide attempts, survivors do not go on to die by suicide, but having access to a gun makes the equation deadly; 85 percent of gun suicide attempts end fatally, while less than 5 percent of non-firearm suicide attempts do. Firearms are the most lethal means of suicide in the U.S., according to the Centers for Disease Control and Prevention (CDC). 

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Despite its toll, suicide may be the firearm-related health risk that we can most successfully address through public-health solutions.  The most important ingredient in reducing firearm suicide (as well as homicide) deaths is a broad-based willingness to construct a path built on common sense and science. One under-explored public health approach I wrote about for The Hill last year would parallel the national campaign to increase motor vehicle safety in our nation by making the offending object safer. 

What if we treated gun ownership like car ownership? As I outlined then, research-based changes have been transformative in reducing the number of traffic deaths, which have declined by 75 percent from 1970 levels. Since then, we have increased vehicle and road safety, installed and required use of  passenger safety devices such as seat belts (which saved 255,000 lives in the U.S. between 1975 and 2008), as well as airbags. National public-safety education programs have also been launched. 

Every American adult has the right to own a motor vehicle but can’t operate one that doesn't meet safety and licensing laws. A similar approach can be used to decrease the number of gun suicides, and we have the advantage of technological innovation. Through smart-gun technology, firearms become “personalized,” useless to all but owners and authorized users. Magnet locks, sensor-activated firearms that identify the authorized user, and pin-enabled locks are all available.

Fingerprint locks work for cell phones and can also work for guns; fingerprint barrel and trigger locks are also just being introduced and Johns Hopkins researchers have developed personalization technology that allows a gun to be fired only when it recognizes a chip in a ring worn by the owner. High-tech gun vaults that encase the trigger and magazine of a rifle can only be released by personalized electronic mechanisms. So far, personalized guns have not taken off in the market; we need to research why and how to leverage their benefits.

You can’t start a car without keys: you should not be able to fire a gun without first unlocking it from a secure state.  Options include trigger locks, gun safes and lock boxes, which are proven effective in preventing unauthorized use and mitigate some risks of firearm suicide by reducing impulsive use. They are highly effective in households with children 19 and under, who are highly impulsive. 

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Approximately 4.6 million American minors live in households with at least one loaded, unlocked firearm. When American teens and children die by firearm suicide, over 80 percent use a family member’s gun. One study found households with locked firearms and ammunition were associated with a 78 percent lower risk of self-inflicted firearm injuries and an 85 percent lower risk of unintentional firearm injuries among teens and younger children, compared to those that locked neither.

As with road safety, communication is among the most promising evidence-based strategies to reduce gun suicide. Working with leaders in the gun community on messages that resonate with gun owners is critical, and social media must be part of that campaign. Through the Gun Shop Project, dozens of gun dealers nationwide display and distribute materials about the risks of firearm access — particularly pertaining to suicide. Several states offer gun suicide prevention guidelines. Most, like Washington, through websites, and some, like Texas, offer an app.

Practices that complement making guns safer limit access or temporarily remove firearms from individuals in crisis. Connecticut’s enactment of PTP laws, requiring individuals to obtain a permit, and point-of-sale background-checks were associated with a 15 percent decline in the firearm suicide rate over the last decade, while Missouri’s repeal of its PTP law correlated with a 16 percent increase in the firearm suicide rate over the following five years. To protect individuals in crisis, 17 states and DC have passed Extreme Risk laws, which allow family and law enforcement to petition for court orders temporarily removing guns from dangerous situations before warning signs turn tragic.

We know that these measures work, but they are piecemeal; we need a comprehensive public health effort to address gun suicide. Public health officials must collaborate with lawmakers and gun owners to free up funding so that the CDC and other qualified researchers can once again research gun suicides, how we can best reduce them, and how our context and opportunities compare to efforts in other countries. But we can only benefit from this research if we are allowed to conduct it, and we can only save lives if we are willing to act upon what we learn.

Jonathan Fielding, M.D., is a professor of public health and pediatrics at University of California, Los Angeles.