Suicide is the 10th-leading cause of death in the U.S. and the second-leading mortality cause among people between 10 and 34 years old, says the Centers for Disease Control and Prevention (CDC). That kind of figure would seem to suggest a nationwide epidemic, yet suicide rates vary dramatically across the 50 states and the variation exceeds that of any of the other nine leading causes of death. Some might hypothesize this has to do with varying rates of depression, anxiety or post-traumatic stress disorder. But according to one researcher, none of those factors makes a significant difference in suicide rates. The main determinant, he said, is access to a gun.
Speaking at the recent “Preventing Gun Violence: Moving From Crisis to Action” event at the American Bar Association (ABA) in Chicago, co-sponsored by the AMA, Matthew Miller, MD, MPH, ScD, compared the current state of gun violence to the dangers of driving before the advent of many car safety features.
“Given that most motor vehicle-related fatalities and crashes are traceable to individual behavior, it would make sense that you would want to focus on the individual, and for years and years, decades and decades, that was the case,” said Dr. Miller, a professor of health sciences and epidemiology at Northeastern University and co-director of the Harvard Injury Control Research Center, in Boston. “We tried to educate people, put them in driver’s ed programs and enforce traffic laws, to little avail.
“And then, around 1950 or thereabouts, physicians started to ask a different question. Instead of asking, ‘Who caused the crash? Was he drunk?’ they started asking … ‘What caused the injury?’”
Driving a car in the ’50s was fraught with injury risks, he said, including non-collapsible steering columns, conventional glass windows, lack of seatbelts and highways lined with trees.
“It’s easier and a lot more effective to alter the environment than it is to try to change human behavior. That’s a central observation that led to an 85 percent reduction in motor-vehicle fatalities [per mile driven],” Dr. Miller noted. “We don’t have trees lining highways any longer, and we have airbags and collapsible steering columns, cars that accordion to absorb the energy. Today, most traffic experts don’t think that drivers are any better than they were back in the ’50s … we just think the cars are safer and the environment is safer.”
Similar approach needed on suicide
Citing a study he co-wrote, Dr. Miller noted that states with high gun ownership have many more firearm suicides than states with low gun ownership. From 2008 to 2009, high-gun-ownership states had 7,275 suicides, compared with 1,697 in low-gun-ownership states. Meanwhile, non-firearm suicides in high-gun and low-gun states were nearly identical—4,153 and 4,341, respectively.
The study suggests that access to a firearm during a suicidal crisis drives higher rates of suicide, not the prevalence of suicidal behavior. Reducing at-risk individuals’ access to guns would not simply shift the methods used toward some other lethal means, he argued, noting that there are three well-established clinical observations that undergird this theory.
“The first is that suicidal acts are often impulsive, and crises are often fleeting,” Dr. Miller said. “The second is that the method that people use is largely dependent on what’s readily available during that crisis, during that impulsive moment. The third is that for people who survive an attempt, the likelihood that they will go on to die by suicide thereafter is under 10 percent. … So if you save someone’s life today, you’ve actually saved their life in the long run.”
As evidence that suicidal crises are fleeting, Dr. Miller cited a survey in which Houstonians between 15 and 35 years old who had attempted suicide were asked how long it took between the moment they decided they were going to commit suicide and the act that landed them in the hospital. One in four said less than five minutes, half said less than 20 minutes and three out of four said less than an hour.
“So what’s available to you during that crisis really matters,” Dr. Miller said, “and the likelihood of dying when you reach for a gun is just enormously higher than the likelihood when you reach for most other things.”
Where physicians come in
One of the challenges to implementing a public health approach to suicide prevention is public opinion of the causes of suicide, even among clinicians, Dr. Miller said. In one survey, only a quarter of health professionals agreed that a gun in the home increases the risk of suicide, and half disagreed with that statement.
Another study Dr. Miller co-wrote analyzed responses from physicians and nurses about how they approached suicidal patients in the emergency department. If patients had suicide plans that involved a firearm, only two-thirds of health professionals asked about guns in the home. If the patients’ plans involved pills or hanging or if they did not have plans but were still suicidal, just one in five health professionals talked to them about guns.
The 11th U.S. Circuit Court of Appeals recently struck down key portions of Florida’s Firearms Owners’ Privacy Act, which restricted the ability of physicians to communicate freely with patients about gun safety. The appeals court ruled that the so-called gun gag law infringed on the free speech rights of physicians.
In his talk, Dr. Miller argued that despite this “hard-won victory” for physicians’ freedom of speech, “legal impediments were never the chief impediments to speaking with patients.” Other factors, which need to be understood better, are interfering with clinicians’ willingness to ask their patients about guns.
“We need to know how to help [physicians] ask in a way that’s more effective,” Dr. Miller said. “The court has done its duty. It’s now the physician’s turn.”
Long-standing AMA policy supports physicians’ conversations with patients about firearm safety and how to protect themselves and their families from gun-related injuries or death. In addition, the AMA House of Delegates recently adopted policy calling gun violence a public health crisis and directing the Association to actively lobby Congress to lift the gun-violence research ban.
In late 2016, the AMA joined an advocacy effort, started by the ABA and leading organizations representing physicians, public health professionals and attorneys, aimed at reducing gun-related deaths and injuries. The “call to action” seeks universal background checks on gun purchases, restrictions on the sale of military-style weapons and large-capacity magazines to civilians and more research on how to cut morbidity and mortality involving firearms.