1-2. Gun availability is a risk factor for suicide (literature reviews).

We performed reviews of the academic literature on the effects of gun availability on suicide rates. The preponderance of current evidence indicates that gun availability is a risk factor for youth suicide in the United States.  The evidence that gun availability increases the suicide rates of adults is credible, but is currently less compelling.  Most of the disaggregate findings of particular studies (e.g. handguns are more of a risk factor than long guns, guns stored unlocked pose a greater risk than guns stored locked) are suggestive but not yet well established.

Miller, Matthew; Hemenway, David. The relationship between firearms and suicide: A review of the literature. Aggression and Violent Behavior: A Review Journal. 1999; 4:59-75.

Miller, Matthew; Hemenway, David. Gun prevalence and the risk of suicide: A review. Harvard Health Policy Review. 2001; 2:29-37.


3. Across states, more guns = more suicide

(cross sectional analyses)

Using a validated proxy for firearm ownership rates, we analyzed the relationship between firearm availability and suicide across 50 states over a ten year period (1988-1997). After controlling for poverty and urbanization, for every age group, across the United States, people in states with many guns have elevated rates of suicide, particularly firearm suicide.

Miller, Matthew; Azrael, Deborah; Hemenway, David. Household firearm ownership levels and suicide across U.S. regions and states, 1988-1997. Epidemiology. 2002; 13:517-524.


4. Across states, more guns = more suicide (2)

(cross sectional analyses)

Using survey data on rates of household gun ownership, we examined the association between gun availability and suicide across states, 1999-2001.  States with higher levels of household gun ownership had higher rates of firearm suicide and overall suicide.  This relationship held for both genders and all age groups.  It remained true after accounting for poverty, urbanization and unemployment.  There was no association between gun prevalence and non-firearm suicide.

Miller, Matthew; Lippmann, Steven; Azrael, Deborah; Hemenway, David. Household firearm ownership and rates of suicide across U.S. states. Journal of Trauma. 2007; 62:1029-35.


5. Across states, more guns = more suicides

(time series analysis)

Using survey data on rates of household gun ownership, we examined the association between gun availability and suicide over time, 1981-2001. Changes in the levels of household firearm gun ownership was significantly associated with changes in both firearm suicide and overall suicide, for men, women and children, even after controlling for region, unemployment, alcohol consumption and poverty. There was no relationship between changes in gun ownership and changes in non-firearm suicide.

Miller, Matthew; Azrael, Deborah; Hepburn, Lisa; Hemenway, David; Lippman, Steven.  “The association between changes in household firearm ownership and rates of suicide in the United States, 1981-2002.” Injury Prevention. 2006; 12:178-82.


6. Across states, more guns = more suicide (Northeast)

We analyzed data on suicide and suicide attempts for states in the Northeast.  Even after controlling for rates of attempted suicide, states with more guns had higher rates of suicide.

Miller, Matthew; Hemenway, David; Azrael, Deborah. Firearms and suicide in the Northeast. Journal of Trauma. 2004; 57:626-632.


7. Across U.S. regions, more guns = more suicide

(cross sectional analysis)

We analyzed the relationship of gun availability and suicide among differing age groups across the 9 US regions. After controlling for divorce, education, unemployment, poverty and urbanization, the statistically significant relationship holds for 15 to 24 year olds and 45 to 84 year olds, but not for 25 to 44 year olds.

Birckmayer, Johanna; Hemenway, David. Suicide and gun prevalence: Are youth disproportionately affected? Suicide and Life Threatening Behavior. 2001; 31:303-310.


8. Differences in mental health cannot explain the regional more guns = more suicide connection.

We analyzed the relationship of gun availability and suicide among differing age groups across the 9 US regions. Levels of gun ownership are highly correlated with suicide rates across all age groups, even after controlling for lifetime major depression and serious suicidal thoughts

Hemenway, David; Miller, Matthew. The association of rates of household handgun ownership, lifetime major depression and serious suicidal thoughts with rates of suicide across US census regions. Injury Prevention. 2002; 8:313-16.


9. Gun owners do not have more mental health problems than non-owners

We added questions to, and analyzed data from the National Comorbidity Study.

Gun owning households do not have more mental health problems than non-gun owning households; differences in mental health do not explain why gun owners and their families are at higher risk for completed suicide than non-gun owning families.

Miller, Matthew; Molnar, Beth; Barber, Catherine; Hemenway, David; Azrael, Deborah. Recent psychopathology, suicidal thoughts and suicide attempts in households with vs. without firearms: findings from the National Comorbidity Study Replication. Injury Prevention. 2009; 15:183-87.


10. Gun owners are not more suicidal than non-owners

We analyzed data from the Second Injury Control and Risk Survey, a 2001-2003 representative telephone survey of U.S. households. Of over 9,000 respondents, 7% reported past-year suicidal thoughts, and 21% of these had a plan.  Respondents with firearms in the home were no more likely to report suicidal thoughts, plans or attempts, but if they had a suicidal plan, it was much more likely to involve firearms.  The higher rates of suicide among gun owners and their families cannot be explained by higher rates of suicidal behavior, but can be explained by easy access to a gun.

Betz, Marian E; Barber, Catherine; Miller, Matthew. Suicidal behavior and firearm access: results from the second injury control and risk survey (ICARIS-2). Suicide and Life Threatening Behaviors 2011; 41:384-91.


11. Adolescents who commit suicide with a gun use the family gun

The vast majority of adolescent suicide guns come from parents of other family members.

Johnson, Rene M; Barber, Catherine; Azrael, Deborah; Clark, David E; Hemenway, David. Who are the owners of firearms used in adolescent suicides? Suicide and Life Threatening Behavior. 2010; 40:609-611.


12. The case-fatality rate for suicide attempts with guns is higher than other methods

Across the Northeast, case fatality rates ranged from over 90% for firearms to under 5% for drug overdoses, cutting and piercing (the most common methods of attempted suicide).  Hospital workers rarely see the type of suicide (firearm suicide) that is most likely to end in death.

Miller, Matthew; Azrael, Deborah; Hemenway, David. The epidemiology of case fatality rates for suicide in the Northeast. Annals of Emergency Medicine. 2004; 723-30.


13. The public does not understand the importance of method availability


Over 2,700 respondents to a national random-digit-dial telephone survey were asked to estimate how many of the more than 1,000 people who had jumped from the Golden Gate Bridge would have gone on to commit suicide some other way if an effective suicide barrier had been installed.  Over 1/3 of respondents estimated that none of the suicides could have been prevented.  Respondents most likely to believe that no one could have been saved were cigarette smokers and gun owners.

Miller, Matthew; Azrael, Deborah; Hemenway, David. Belief in the inevitability of suicide: Results from a national survey. Suicide and Life Threatening Behavior. 2006; 36:1-11.


14. Physicians need to do more to help reduce access to lethal means

This commentary presents the overwhelming evidence that the availability of lethal means increases the suicide rate and argues that physicians need to take an active role in reducing access for potentially suicidal individuals.

Miller, Matthew; Hemenway, David. Guns and suicide in the United States. The New England Journal of Medicine. 2008; 359:989-991.


15. ED physicians and nurses rarely counsel about lethal means restriction

In one Boston emergency department, ED physicians and nurses believe they should counsel suicidal patients on lethal means restriction, but they often don’t.  Psychiatrists working at the ED were much more likely to ask about firearms.

Betz, Marian E; Barber, Catherine; Miller, Matthew. Lethal means restriction as suicide prevention: variation in belief and practices among providers in an urban ED. Injury Prevention. 2010; 16:278-81.


16. ED physicians and nurses do not believe lethal means restriction can prevent suicide

Physicians and nurses at 8 emergency departments were surveyed about their belief concerning means restriction and whether they asked their patients about guns.  Two thirds of nurses thought that most firearm suicide decedents would have died by another method if the firearm had not been available.

Betz, Marian E; Miller, Matthew; Barber, Catherine et al.. Lethal means restriction for suicide prevention: beliefs and behaviors of emergency department providers. Depression and Anxiety, 2013 in press.


17. Mental health providers can be trained to reduce the risk of gun suicide

The CALM workshops were effective in improving mental health care providers’ attitudes, beliefs and skills regarding lethal means counseling.

Johnson, Rene M; Frank, Elaine; Ciocca, Mark; Barber, Catherine. Training mental health providers to reduce at-risk patients’ access to lethal means of suicide: Evaluation of the CALM project. Archives of Suicide Research. 2011 15(3):259-264.


18. Suicide training in means reduction can be accomplished via the internet

This article describes HICRC’s National Center for Suicide Prevention Training, which uses the public health approach and includes training on means restriction.

Stone, Deborah; Barber, Catherine, Posner, Marc. Improving public health practice in suicide prevention through online training: a case example. In: Sher, Leo & Vilens, Alexander., eds. Internet and Suicide. New York: Nova Science, 2009.


19. Lethal means reduction strategies can successfully reduce suicide

This article summarizes recent additions to the scientific literature about means restriction policies and suicide

Johnson, Rene M; Coyne-Beasley, Tamera. Lethal means reduction: what have we learned? Current Opinion in Pediatrics. 2009; 21: 635–640


20. Veterans have high rates of firearm suicide

There are no differences in suicide risk among middle-aged and older male veterans and non-veterans.  Suicide by firearm is higher, suicide by non-firearm is lower.  It is probable that lower baseline risk of active duty soldiers (healthy worker effect) tend to be counterbalanced by the accessibility of firearms to these veterans.

Miller, Matthew; Barber, Catherine; Azrael, Deborah, Calle, Eugenia E; Lawler, Elizabeth; Mukamal, Kenneth J. Suicide among US veterans: a prospective study of 500,000 middle-aged and elderly men.  American Journal of Epidemiology. 2009; 170:494-500.


21. There are effective ways to reduce suicide without affecting mental health

This introduction to suicide as an international public health problem examines the role of promoting mental health, changing cultural norms, and reducing the availability of lethal means in preventing suicide

Barber, Catherine; Miller, Matthew.  A public health approach to preventing suicide. In: Finkel, Madelon L.  Perspectives in Public Health:Challenges for the Future. Santa Barbara CA: Praeger Publishers, 2010.


22. Differences in suicide rates across the US are best explained by gun prevalence

This summary of the scientific literature on suicide in the United States emphasizes the importance of levels of household firearm ownership in explaining different rates of suicide over time and across states, households and genders.

Miller, Matthew; Azrael, Deboarh; Barber, Catherine. Suicide mortality in the United States: The importance of attending to method in understanding population-level disparities in the burden of suicide. Annual Review of Public Health 2012;33:393-408.


23. Reducing access to lethal means can begin to reduce suicide rates today

This editorial in an issue of the flagship public health journal devoted entirely to veteran suicide emphasizes the importance of the availability of firearms in determining whether suicide attempts prove fatal.

Miller, Matthew. Preventing suicide by preventing lethal injury: the need to act on what we already know. American Journal of Public Health 2012; 102(S1):e1-3.


24. The main factor explaining differences in suicide rates across states is gun ownership

Even after accounting for suicide attempt rates, levels of firearm ownership largely explain the variation in suicide mortality across the 50 states.

Miller, Matthew; Barber, Catherine; Azrael, Deborah; White R. .Firearms and suicide in the United States: is risk independent of underlying suicidal behavior?  American Journal of Epidemiology 2013.