Despite a considerable array of anti-depressant and other kinds of medications available to treat mental illnesses, particularly depression, suicide rates in the US have remained steady for the past 50 years, according to the National Center for Injury Prevention and Control. More than 28,000 Americans kill themselves each year.

To put suicide rates in perspective, from 1979 to 1999, more than 448,000 Americans died of AIDS or HIV-related illnesses while, during the same period, more than 626,225 people killed themselves, according to a new report from the Institute of Medicine (IOM). More than three times the number of Americans committed suicide from 1964 to 1973 than were killed in the Vietnam War during the same period.

The Harvard Injury Control Research Center (HICRC) at HSPH has investigated suicide and its relationship to firearms, revealing important statistical information about the problem. Several HICRC members spoke at the Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control 10th Anniversary Conference in Boston on June 19, participating in a "Suicide Prevention Workshop." HICRC serves as the New England center for the National Center for Injury Prevention and Control.

The CDC has received $1.5 million to get a National Violent Death Reporting System (NVDRS) underway. The money will be used to continue planning and to begin implementation of the system in selected states. The funding is a start, but fully implementing the system will cost about $20 million a year–or a fraction of the billions spent annually on medical care for violent injuries.

When fully implemented, NVDRS would assemble and link data about all violent deaths in the country, including suicides. The data have already been collected by medical examiners and others but are currently often filed away in boxes or cabinets, said David Hemenway, a professor in the Department of Health Policy and Management and director of HICRC. NVDRS would be similar to one created by the National Highway Traffic Safety Administration (NHTSA) in 1975 that assembles data on fatal motor vehicle crashes throughout the country. The NHTSA system has been used to assess the impact of interventions such as anti-drunk driving campaigns.

HICRC is the coordinating center for the National Violent Injury Statistics System (NVISS), which includes a pilot for NVDRS and also includes a system for non-fatal violent injuries.

Catherine Barber, co-director of NVISS, described findings from the pilot project at the CDC workshop.

NVISS includes 13 sites in Connecticut, Maine, Maryland, Michigan, Utah, Wisconsin, Allegheny County, PA, Miami-Dade County, FL, metropolitan Atlanta and San Francisco.

Barber reported on preliminary data collected in 2000 from 521 cases involving suicides and firearms. The gender of the suicide victims was overwhelmingly male, who represented 90 percent of the cases. More than 60 percent of the cases involved people between the ages of 25 and 64; 15 percent involved children and young adults under the age of 25; and more than 20 percent involved people older than 65 years.

A significant number were reported as having been depressed, having some other mental disorder or having a substance abuse problem. Only 18 percent were reported as having been in treatment before they killed themselves, and the proportion of women who received treatment was twice as high as the proportion of men who received treatment

Impulsiveness in a number of the cases was detected, with people in 20 percent of 420 cases killing themselves on the same day that a crisis occurred. Others killed themselves after a very recent crisis or in anticipation of an impending one. Young people were at particular risk for impulsive suicide with almost half killing themselves on the same day as, or within two weeks of, a crisis. Examples of crises were arrests, job losses and, for younger people, bad report cards. Other factors, such as underlying mental health conditions, may have influenced the impulsive suicides.

There is a sense that the impulsive suicides may have been averted if people had allowed time to get through the crisis, said Barber. She added that having access to a gun increases the chances of a fatal suicide attempt.

Data revealed a group of suicide victims who are not ordinarily perceived as vulnerable–violence perpetrators, who represented 49 of the 521 cases in Barber’s report. In 48 of the 49 cases, the perpetrators were men, and in 40 of the 49 cases, intimate partner violence, family violence or child sexual abuse was involved. Barber also presented findings on homicides reported to the pilot system. Among 247 homicide victims, 19 were women killed by an intimate partner. Among the men who killed their partners, 11 (58 percent) also killed themselves during the same incident. While recognizing the focus on protecting women and children in domestic violence cases, Barber suggested that the current policy of removing guns from the possession of perpetrators named in a domestic violence restraining order may actually save men’s lives because of their risk for suicide.

There are more suicides in the US each year than there are homicides, said Matthew Miller, associate director of HICRC. The IOM reports that the ratio of suicides to homicides in the country over the past 100 years is approximately three to two.

Miller’s talk was on "Exploring the Relationship between Suicide Rates, Gun Availability and Sociodemographic Characteristics," research he has done with Hemenway and Deborah Azrael, co-director of the National Violent Injury Statistics System at HICRC.

Firearms are the leading way Americans kill themselves. They are involved in 56 percent of suicide cases, as compared to 19 percent using suffocation methods, 17 percent using poison, two percent using jumping and six percent using other means.

More than 200 million guns are in the possession of American civilians, he said. The US has approximately 280 million people.

"You cannot talk about suicide in the United States without also talking about guns," said Miller.

Studies indicate that having a gun is a strong risk factor for suicide and that risk is elevated for all age groups, said Miller. Research at HICRC has indicated that states with high levels of gun ownership have higher rates of overall suicides compared to states with low levels of gun ownership.

He reiterated that both men and women use firearms to kill themselves. Far more men and women attempt suicide using drugs and knives, but the case fatality rate from gun attempts is so high that the majority of suicide deaths are firearm deaths.

Miller offered some take-home messages from HICRC’s research: guns are lethal; suicidal crises can be temporary; and suicidal acts are often impulsive. He suggested that people be spoken to respectfully about the dangers posed by firearms when they are screened for suicide risk or are in crisis.

For more information, visit http://www.hsph.harvard.edu/hicrc/.