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Effects of Risk-Based Firearm Seizure Laws in Connecticut and Indiana on Suicide Rates, 1981–2015
Abstract
Objective: This study evaluated whether risk-based firearm
seizure laws in Connecticut and Indiana affect suicide rates.
Methods: A quasi-experimental design using annual state-level
panel data from the 50 states between 1981 and 2015
was used. When analyses controlled for a range of risk factors
for population-level suicide rates, the effects of Connecticut
and Indiana’s firearm seizure laws on firearm and
nonfirearm suicide rates were evaluated by using the
synthetic-control methodology and difference-in-place
placebo tests. Sensitivity analyses employed regression-based
difference-in-differences analyses with randomization
inference.
Results: Indiana’s firearm seizure law was associated with a
7.5% reduction in firearm suicides in the ten years following
its enactment, an effect specific to suicides with firearms and
larger than that seen in any comparison state by chance
alone. Enactment of Connecticut’s law was associated with
a 1.6% reduction in firearm suicides immediately after its
passage and a 13.7% reduction in firearm suicides in the
post–Virginia Tech period, when enforcement of the law
substantially increased. Regression-based sensitivity analyses
showed that these findings were robust to alternative
specifications. Whereas Indiana demonstrated an aggregate
decrease in suicides, Connecticut’s estimated reduction in
firearm suicides was offset by increased nonfirearm suicides.
Conclusions: Risk-based firearm seizure laws were associated
with reduced population-level firearm suicide rates,
and evidence for a replacement effect was mixed.
... These programs enable law enforcement, health professionals, and families to intervene when individuals are dangerous to themselves or others. ERPOs or GVROs were associated with a 7.5% reduction of firearm suicide rate in Indiana and a 14% reduction in Connecticut [151]. ...
... An increased presence of gun shops is associated with higher suicide rates, underscoring the need for more lethal means safety programs of this nature [79]. These are all very positive steps in the right direction with demonstrated efficacy in reducing suicide deaths [142,151,156]; thus, the importance of these measures for improving public health cannot be overstated. ...
... England, Finland, and Denmark have invested resources to carefully address suicide at the population level, by using multiple coordinated elements to reduce access to lethal means while enhancing access to mental health services [192][193][194]. Furthermore, sensible and situationally/geographically appropriate means reductions approaches are demonstrably effective for reducing suicides by highly lethal means [97,106,114,118,130,131,142,143,151,156,157,195]. Yet similar large-scale, integrated, and coordinated public health approaches to suicide prevention has not yet been widely applied in the United States. ...
Suicide rates in the United States (US) reached a peak in 2018 and declined in 2019 and 2020, with substantial and often growing disparities by age, sex, race/ethnicity, geography, veteran status, sexual minority status, socioeconomic status, and method employed (means disparity). In this narrative review and commentary, we highlight these many disparities in US suicide deaths, then examine the possible causes and potential solutions, with the overarching goal of reducing suicide death disparities to achieve health equity.
The data implicate untreated, undertreated, or unidentified depression or other mental illness, and access to firearms, as two modifiable risk factors for suicide across all groups. The data also reveal firearm suicides increasing sharply and linearly with increasing county rurality, while suicide rates by falls (e.g., from tall structures) decrease linearly by increasing rurality, and suicide rates by other means remain fairly constant regardless of relative county urbanization. In addition, for all geographies, gun suicides are significantly higher in males than females, and highest in ages 51–85 + years old for both sexes. Of all US suicides from 1999–2019, 55% of male suicides and 29% of female suicides were by gun in metropolitan (metro) areas, versus 65% (Male) and 42% (Female) suicides by gun in non-metro areas. Guns accounted for 89% of suicides in non-metro males aged 71–85 + years old. Guns (i.e., employment of more lethal means) are also thought to be a major reason why males have, on average, 2–4 times higher suicide rates than women, despite having only 1/4—1/2 as many suicide attempts as women. Overall the literature and data strongly implicate firearm access as a risk factor for suicide across all populations, and even more so for male, rural, and older populations.
To achieve the most significant results in suicide prevention across all groups, we need 1) more emphasis on policies and universal programs to reduce suicidal behaviors, and 2) enhanced population-based strategies for ameliorating the two most prominent modifiable targets for suicide prevention: depression and firearms.
... While many states have enacted this legislation following mass shootings to prevent at-risk individuals from harming others, studies have shown that the laws have primarily functioned as a means to prevent individuals from harming themselves. For example, Kivisto and Phalen (2018) found a reduction in firearm suicides following the enactment of the legislation in Indiana and increased enforcement of the law in Connecticut after the Virginia Tech mass shooting. Although there is limited information on the characteristics of individuals who are the target of an ERPO, the reasons for an ERPO, and the removal process of ERPOs, it is expected that this proactive approach reduces the prevalence of homicides and suicides in places where they are being served. ...
... First, the degree and level of enforcement following the passage of gun control legislation influences the size and type of effect it has on different outcomes. For example, Kivisto and Phalen (2018) found a greater reduction in firearm suicides eight years after the passage of the ERPO law given the increased enforcement due to a high-profile mass shooting. Other studies have applied different measures assuming a delayed enforcement in legislation by examining outcomes several months or years after the passage of gun legislation. ...
... While the percentage of denied firearms licenses and firearms licenses application had little to no effect on violent crimes, it is clear that a long-term examination of legislation is necessary given the length of time it takes for agencies to implement gun control legislation. Furthermore, previous studies have shown that there may be a longer lag than expected in the level of enforcement following the passage of gun control legislation unless it follows a high-profile mass shooting (Kivisto & Phalen, 2018). ...
Over the last decade, high-profile mass shootings in the United States have brought gun policies back to the front of the public policy debate. While public members remain divided on a number of gun policies, background checks and licensing policies have drawn bipartisan support despite the limited research of their effects on crime reduction. This study examines the impact of background checks and licensing policies following the passage of the 2014 Massachusetts gun legislation on violent crimes in counties from 2006 to 2016. Using population-averaged negative binomial regression models with fixed effects and robust standard errors, the findings show mixed effects of the background checks and licensing process on different categories of violent crimes. While the analysis suggests that the state’s background checks and licensing policies have a negative effect on rape, the models for robbery indicate a positive effect while controlling for other variables. The mixed findings suggest that there are opportunities for other states to reduce violent crimes by adopting similar background check and licensing policies.
... Such a court order can prevent the at-risk person from purchasing or possessing guns, or remove any firearm from their possession. These laws reduced gun suicides by 7.5% in Indiana and 13.7% in Connecticut (Kivisto and Phalen, 2018). However, much of the literature of the impact of firearm laws on suicide, including Kivisto and Phalen, 2018, is focused on a single type of law, with no adjustments for other types of laws which often are in effect at the same time. ...
... These laws reduced gun suicides by 7.5% in Indiana and 13.7% in Connecticut (Kivisto and Phalen, 2018). However, much of the literature of the impact of firearm laws on suicide, including Kivisto and Phalen, 2018, is focused on a single type of law, with no adjustments for other types of laws which often are in effect at the same time. A panel analysis of the effect of the passage of 10 types of firearm laws on suicide rates in the 50 states from 1991 to 2016 found only two that had independent effects on suicide rates. ...
... Political constructs that act as protective factors against suicide include social welfare expenditures (Flavin and Radcliff, 2009;Minoiu and Andres, 2008;Rambotti, 2020;Tuttle, 2018), laws restricting access to firearms and also laws restricting access to alcohol (Hahn et al., 2005;Kivisto and Phalen, 2018;Xuan et al., 2016). One apparently expeditious political factor, increasing the minimum wage faster than inflation (Gertner et al., 2019;Kaufman et al., 2020), is the seen as the most politically possible strategy in the recent work of Anne Case and her husband, the Nobel Prize in Economics winner, Angus Deaton, for decreasing suicide as well as other "deaths of despair" (Case and Deaton, 2020). ...
This review summarizes recent research in four environmental areas affecting risk of deaths by suicide. Politically, the weight of the evidence suggests that laws increasing social welfare expenditures and other policies assisting persons with low incomes (e.g., minimum wage) tend to lower suicide rates. Other legal changes such as those restricting firearms and alcohol availability can also prevent suicides. The social institutions of marriage, as well as parenting, continue to serve as protective factors against suicide, although the degree of protection is often gendered. Religiousness tends to be inversely associated with suicide deaths at the individual level of analysis, but the mediators need exploration to determine what accounts for the association: social support, better mental health, better physical health, less divorce, or other covariates. Cultural definitions of the traditional male role (e.g., breadwinner culture) continue to help explain the high male to female suicide ratio. New work on the "culture of suicide" shows promise. The degree of approval of suicide is sometimes the single most important factor in predicting suicide. At the individual level of analysis, two of the strongest predictors of suicide are economic ones: unemployment and low socio-economic status. Attention is drawn to enhancing the minimum wage as a policy known to lower state suicide rates. Limitations of research include model mis-specification, conflicting results especially when ecological data are employed, and a need for more research exploring moderators of established patterns such as that between religiousness and suicide.
... 9 Some aspects of ERPO implementation are common across several states, such as ERPOs steadily increasing over time and respondents most often being White men. 8,10,11 In Connecticut, ERPOs were used between 1999 and 2013 primarily in response to threats of suicide rather than interpersonal violence, which is similar to findings from Indiana. 9 In contrast, data from California, 5 Washington, 6 and Colorado 8 indicate that ERPOs are utilized most often to prevent harm to others. In Oregon, the percentage of ERPOs related to suicidality and threats of violence against others was roughly the same, with most of the sample indicating both risks. ...
... 6,9,11 In addition, most states adopted ERPO laws relatively recently, and longitudinal analyses of trends have only been possible in Connecticut and Indiana to date. 3,9,10 Thus, our study is an important addition to the literature regarding circumstances and characteristics of respondents, clinically relevant information about respondents' mental health and substance use, potential self-harm and harm to others, and treatment usage. ...
Twenty-one states and the District of Columbia have enacted Extreme Risk Protection Order (ERPO) statutes, which allow temporary removal of firearms from individuals who pose an imminent risk of harm to themselves or others. Connecticut was the first state to enact such a law in 1999. The law's implementation and use between 1999 and 2013 were previously described, finding that ERPOs were pursued rarely for the first decade and that most orders were issued in response to concerns about suicide or self-harm rather than about interpersonal violence. The current study analyzes over 1,400 ERPOs in Connecticut between 2013 and 2020 in several domains: respondent demographics, circumstances leading to ERPO filing, type of threat (suicide, violence to others, or both), number and type of firearms removed, prevalence of mental illness and drug and alcohol use, and legal outcomes. Results are similar to the earlier study, indicating that ERPO respondents in Connecticut are primarily White, male, middle-aged residents of small towns and suburbs who pose a risk of harm to themselves (67.9%) more often than to others (42.8%). Significant gender differences between ERPO respondents are discussed, as are state-specific trends over time and differences between Connecticut and other states with published ERPO data.
... Uses of ERPOs While typically passed in the wake of mass shootings or other high-profile incidents, ERPOs may also be used to prevent other types of firearmrelated harm. Research on analagous risk warrant laws in Indiana and Connecticut suggests that these policies are effective tools for suicide prevention [22][23][24], and emerging data from other states suggests that a majority of ERPOs sought are for cases of risk of harm to self or harm to self and others [25]. Emerging evidence indicates, and experts agree, that ERPOs may be used to remove firearms when someone with cognitive impairment or dementia poses an extreme risk [26,27]. ...
... When this information did appear, ERPOs for preventing mass shootings were most often mentioned (15% of articles), closely followed by preventing firearm suicide (12% of articles). This highlights a strategic opportunity in the wake of mass shootings to shift the narrative to ensure that the impacts of other types of day-to-day firearm violence, which are more common and make up a much larger share of firearm injuries and deaths, are not ignored, particularly in light of evidence suggesting that ERPO-type laws are particularly effective at preventing firearm suicide [22][23][24]. ...
Background
Following the 2018 mass shooting at Marjory Stoneman Douglas High School in Parkland, Florida, there was a dramatic increase in media coverage of extreme risk protection orders (ERPOs) and in state policy proposals for ERPO laws. This study documents the frequency of news coverage of ERPOs throughout 2018 and examines the narratives used by media outlets to describe this risk-based firearm policy.
Methods
Using a mixed-method descriptive design, we examine the frequency of national news media coverage of ERPO legislation in 2018, before and after the Parkland shooting, and analyze the content of news articles related to a sample of states that considered ERPO legislation after the shooting.
Results
We find a sharp increase in the frequency of articles related to ERPOs following the Parkland shooting and smaller increases in coverage surrounding ERPO policy proposals and other public mass shootings that year. Nearly three-quarters of articles in our content analysis mentioned the Parkland shooting. The news media often mentioned or quoted politicians compared to other stakeholders, infrequently specified uses for ERPOs (e.g., prevention of mass violence, suicide, or other violence), and rarely included evidence on effectiveness of such policies. More than one-quarter of articles mentioned a mass shooting perpetrator by name, and one-third of articles used the term “gun control.”
Conclusions
This study describes the emerging public discourse, as informed by media messaging and framing, on ERPOs as states continue to debate and implement these risk-based firearm violence prevention policies.
... Similar warrant-based extreme risk laws have existed in Connecticut and Indiana since 1999 and 2005, respectively, which are more limited than ERPOs in that they do not prevent unarmed individuals from purchasing firearms and can only be sought by law enforcement officers. These laws appear to be effective at preventing firearm suicide [5][6][7]. While the are required to request the immediate relinquishment of firearms by GVRO respondents upon service, but if the respondent refuses, they are not authorized to seize firearms without a search warrant unless the firearms are in plain sight. ...
... These factors fell into 4 CFIR domains: intervention characteristics (risk, cost, adaptability), outer setting (interagency coordination, local firearm ideology), inner setting (readiness for implementation, culture), and implementation process (planning, engaging). Key informants overwhelmingly believed the law to be a useful tool for violence prevention, echoing existing data supporting these orders' effectiveness in preventing suicide [5][6][7]. ...
Background
Uptake of gun violence restraining orders (GVROs), which temporarily prohibit the possession and purchase of firearms and ammunition from individuals at particularly high risk of harming themselves or others with a firearm, has been slow and heterogenous across California. Insights into the implementation process and perceived effectiveness of the law could guide implementation in California and the many states that have enacted or are considering enacting such a law.
Methods
We conducted 21 semi-structured interviews with 27 key informants, including judges, law enforcement officers, city and district attorneys, policy experts, and firearm violence researchers. Analysis of transcripts was guided by grounded theory and the Consolidated Framework for Implementation Research (CFIR).
Findings
The following constructs emerged within 4 CFIR domains as salient features of implementation: 1) implementation characteristics: risk of violence, cost, and adaptability; 2) outer setting: interagency coordination and local firearm ideology; 3) inner setting: readiness for implementation and law enforcement firearm culture; and 4) implementation process: planning and engaging with those involved in implementation. Key informants perceived the law to be effective, particularly for preventing firearm suicide, but agreed that more research was needed. While most indicated that the law resulted in positive outcomes, concerns about the potential for class- and race-based inequities were also raised.
Conclusions
Implementation of the GVRO law in California was hampered by a lack of funding to support local proactive implementation efforts. This resulted in ad hoc policies and procedures, leading to inconsistent practices and widespread confusion among those responsible for implementation. In states that have not begun implementation, we recommend dedicating funding for implementation and creating local procedures statewide prior to the law’s rollout. In California, recommendations include providing training on the GVRO law—including an explication of agency-specific roles, responsibilities, and procedures—to officers, city attorneys, and civil court judges.
... According to a report compiled by Everytown for Gun Safety (2023), there were only 20,440 petitions filed throughout the entire history ofred flag laws. Due to this lack of data and the relatively infrequent use ofred flag laws, empirical research on red flag laws is limited (Gius, 2020;Kivisto and Phalen, 2018;Swanson et al., 2017;Parker, 2015). ...
The purpose of the present study is to determine if there is a relationship between red flag laws and mass shootings. Mass shootings may be averted if the potential shooter’s firearms are seized per a warrant emanating from a red flag statute. Using a fixed effects model and a propensity score matching model, it was found that red flag laws are not significantly related to the number of mass shooting victims (killed and injured). One potential reason for this result is the rarity of mass shootings and the infrequency with which red flag laws are used. Data used in the present study are for the period 1999 to 2020. Mass shootings data were obtained from the Mother Jones mass shooting database. The present study is the first study in the English language literature to examine the relationship between red flag laws and mass shootings.
... As of 2023, 19 states have adopted ERPO laws, some of which also provision for emergency cases via ex parte ERPOs. Empirical evidence suggests that these laws contribute to decreased rates of suicides and homicides involving firearms (Gius 2020;Kivisto & Phalen 2018;Swanson et al. 2017Swanson et al. , 2019. ...
This in-depth review delves into the multifaceted realm of mass shootings and explores their epidemiology from a psychological perspective. The article presents a comprehensive examination of the prevalence, perpetrator and victim profiles, motives, and contributing factors associated with mass shootings. By investigating the intricate relationship between masculinity, domestic violence, military service, social media, fame-seeking, suicidal ideation, mental illness, and firearms, this article sheds light on the multifaceted nature of mass shootings. Moreover, it discusses the importance of implementing effective prevention strategies to address this growing public health concern. The findings from this review serve as a valuable resource for researchers, practitioners, policy makers, and the community at large, facilitating a deeper understanding of mass shootings and fostering the development of evidence-based solutions to prevent these tragic incidents.
Expected final online publication date for the Annual Review of Clinical Psychology, Volume 20 is May 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
... The number of states with Extreme Risk Protection Orders, commonly known as "red flag" laws, has increased since 2018 (to 20 as of June 2023). Red flag laws provide legal authority to temporarily remove firearms and ammunition from a person who demonstrates immediate or imminent risk for gun violence or prohibit the person from purchasing a firearm (48), and were found to have had positive impact in preventing firearm suicides in Connecticut and Indiana that adopted the laws early on (49). However, many states are without the laws and unlikely to adopt it as they are viewed to infringe on the Second Amendment right to bear arms (50). ...
Background and aims
A majority of older adult suicide decedents used firearms. In this study, we focused on suicide decedents age 75+ who disclosed their suicidal intent within a month of their injury/death to examine demographic and clinical characteristics associated with firearm use and firearm access restriction attempts by their family members.
Methods
The 2017–2019 U.S. National Violent Death Reporting System provided data (N = 1,734 suicidal intent disclosers; 1,476 males and 258 females; 21.4% of decedents age 75+). Generalized linear model (GLM) for a Poisson distribution with a log link was used to examine firearm use risk factors. Firearm access restriction attempts by decedents' family members were examined based on coroner/medical examiner and law enforcement (CME/LE) reports.
Results
Nearly three quarters of disclosers disclosed their intent to family members, and 82.9% of males and 27.5% of females used firearms. GLM results showed males, non-Hispanic white people, and residents in the South and West regions had higher likelihood of firearm use. CME/LE reports of 140 out of 1,294 firearm decedents included narratives related to firearm restriction attempts or lack thereof. Firearm access restrictions were not attempted in 65 cases because family members did not take suicidal intent disclosure seriously or because decedents promised no self-harm. Partial or complete removal of firearms in 75 cases were not effective as decedents had hidden a firearm or purchased a new one. Others used different lethal methods.
Implications
The findings indicate a need for: (a) training family members of older adults who are at risk of suicide in effective means safety/access restriction and strategies to prevent means substitution; (b) more comprehensive legislative reforms reducing access to firearms by those at risk of suicide; and (c) more comfort and palliative care and counseling for psychosocial risk factors.
... Previous research on the effectiveness of ERPOs have found promising results suggesting ERPOs are effective tools to prevent firearm suicide deaths. One study evaluating Connecticut and Indiana ERPO laws found law implementation was associated with a 7.6% reduction in Indiana's firearm suicide rate over ten years, and a reduction of 13.7% in Connecticut after enforcement was increased (Kivisto and Phalen, 2018). A similar study of Connecticut's law estimated one suicide death may be prevented for every ten to twenty firearm seizures (Swanson et al., 2022). ...
Extreme Risk Protection Orders (ERPOs) temporarily restrict access to firearms if an individual is deemed a significant risk of harm to themselves or others. Some states allow clinicians to initiate ERPO petitions for their patients and a new Justice Department model statute recommends clinicians should be eligible petitioners. Washington clinicians cannot currently file ERPOs independently. This article presents the results of an electronic survey of all actively licensed Washington physicians and advanced registered nurse practitioners in 2021 to gauge clinicians’ familiarity, willingness, barriers, facilitators, and preferences for initiating ERPOs by counselling a patient or patient’s family, contacting law enforcement, or filing independently.
3,021 clinicians responded. 75.2% were not familiar with ERPOs but reported being willing to counsel patients about ERPOs if they encountered a patient at substantial risk of harm to themselves (96%) or others (97%). Counselling was the preferred approach to filing; however, approximately 75% would be willing to file independently if allowed. Lack of knowledge about ERPOs was the most reported barrier and training the most common facilitator for all initiation approaches. Having a trained social worker to refer patients (81.5%), an ERPO liaison to law enforcement (70.9%), or coordinator to assist with filing (71.3%) was highly desired. Survey response rates were: 13.5% for physicians, 17.2% for nurse practitioners.
Washington clinicians are willing to use ERPOs for their patients, but they need training. Counselling was the preferred initiation approach, and there was a strong preference for a social worker or ERPO coordinator to assist in counseling and filing.
... For example, Kivisto and Phalen's synthetic control study estimated that Indiana's ERPO law resulted in a 7.5 percent reduction in firearm suicide in Indiana and a 13.7 percent reduction in Connecticut. 33 Swanson et al.'s studies of the effects of ERPO legislation also supported decreased firearm suicide among individuals subject to firearm seizures in Connecticut and Indiana. 34,35 Notably, these authors estimated that one firearm suicide was averted for every 10.6 seizures that occurred in Connecticut . ...
Restricting suicidal individuals’ access to firearms is essential in the United States where firearms, which are unique in the combination of lethality and widespread availability, account for approximately half of all suicides. Although not typically conceived of as a suicide prevention tool by policymakers, ERPO laws have functioned primarily as legislated firearm restriction policies in their implementation, most commonly targeting suicidal individuals. Further, data suggest that these laws are effective, with estimates suggesting that one suicide might be averted for every 10 or 11 firearm seizures carried out under ERPO statutes. Relative to other common pharmacologic and psychosocial approaches to suicide prevention, ERPO laws may be uniquely efficient, likely due to their effectiveness in narrowly directing firearm seizures toward individuals who present an extremely high risk of suicide.
Building on the knowledge gained from ERPO laws regarding their role in the pantheon of suicide prevention tools, the promotion of nonlegalistic means restriction approaches appears desirable, including more widespread dissemination of firearm safety counseling strategies and the development of social norming approaches that promote a shared sense of responsibility for keeping firearms away from family and friends in crisis. Although ERPO laws will continue to play an important role where other, less coercive interventions have failed, it is hoped that this commentary also promotes interest among psychiatrists in nonlegalistic firearm means restriction approaches to suicide prevention.
... First, state-level policies strengthening firearm legislation may reduce firearm parricide rates. Although this study did not directly examine the association between parricide and firearm legislation, such as mandatory background checks, permit-to-purchase laws, and extended waiting periods, several studies have found an association between such laws and reduced rates of firearm homicide, suicide, and injury (e.g., Fleegler et al., 2013;Kivisto et al., 2017;Kivisto and Phalen, 2018;Webster et al., 2014). Second, the presence of unlocked guns in the home has been linked to an increased risk of unintentional and intentional shootings resulting in injury and death (Monuteaux et al., 2019). ...
The association between firearm ownership and homicide has been shown to be specifically related to homicides involving intimate partners and other domestic relations. Prior research has shown that firearms are commonly used in parricide, and in particular parricides perpetrated by youth. This study examined whether higher levels of firearm ownership are associated with increased rates of parricide, and whether this association was stronger among youthful offenders. We used a longitudinal design and negative binomial regression to model parricide as a function of household firearm ownership at the state level using data from the Federal Bureau of Investigation's Supplementary Homicide Reports from 1981 through 2018. There were 8,916 parricide perpetrators in the study sample, and nearly half used a firearm (47.7%). Whereas parricides committed by adults involved firearms in 43.5% of cases, almost two-thirds (64.8%) of parricides committed by youth involved firearms. Each 1-percentage point increase in state-level household firearm ownership was associated with a 1.5% increased incidence of parricide (95% CI = [0.6%, 2.4%], p = .001). Moderation analyses revealed that the association between state-level firearm ownership and parricide was between 2.6-and 3.6-fold stronger for incidents perpetrated by youth relative to adults. Reducing youth access to firearms in the context of conflictual parent-child relations represents one strategy for reducing parricide.
... [44][45][46][47][48] At the state and national levels, multiple studies have reported on the success and importance of firearm regulation legislation. 27,[49][50][51][52][53][54][55][56] Additional research is warranted to better elucidate how the risk of firearm-related death may change along with changes in the poverty concentration of a community over time, as well as how the risk conferred by the length of time spent in a community with a high poverty level may modulate one's risk of firearmrelated death. Although this study focused on firearm-related deaths, most people who experience firearm violence survive but with substantial detrimental physical, mental health, and community-related outcomes. ...
Importance
Youth firearm-related deaths are a public health crisis in the US. The association between county-level poverty and the risk of firearm-related deaths among youth is unknown, however.
Objective
To examine the association between county-level poverty concentration and firearm-related mortality rates in US youth.
Design, Setting, and Participants
This cross-sectional study analyzed US firearm fatalities in children and young adults aged 5 to 24 years that occurred between January 1, 2007, and December 31, 2016. Data were obtained from the Centers for Disease Control and Prevention’s Compressed Mortality File, and annual intercensal county population data were obtained from the US Census Bureau. Data analyses were conducted between November 1, 2019, and June 30, 2020.
Exposures
County-level poverty was categorized into 5 groups: 0% to 4.9%, 5% to 9.9%, 10% to 14.9%, 15% to 19.9%, and ≥20% of the population living below the federal poverty level.
Main Outcomes and Measures
The main outcomes were firearm-related deaths in total and by specific intent (homicide, suicide, and unintentional) per 100 000 youths over the entire study period. Multivariable negative binomial regression models were used to analyze the association between firearm-related mortality rates and county poverty concentration, controlling for demographic variables, urbanicity, and statewide firearm prevalence. Adjusted incidence rate ratios (IRRs) were calculated, and statewide firearm prevalence was estimated. The population-attributable fraction (PAF) and years of potential life lost for each intent were calculated.
Results
A total of 67 905 firearm-related deaths among youth (predominantly composed of 60 164 male individuals [88.6%]) from 2007 to 2016 were analyzed. Of these deaths, 42 512 were homicides (62.6%), 23 034 were suicides (33.9%), and 1627 were unintentional (2.4%). Firearm-related mortality risk increased in a stepwise manner with increasing county poverty concentration. Compared with counties with the lowest poverty concentration, counties with the highest poverty concentration had an increased rate of total firearm-related deaths (adjusted IRR, 2.29; 95% CI, 1.96-2.67), homicides (adjusted IRR, 3.55; 95% CI, 2.80-4.51), suicides (adjusted IRR, 1.45; 95% CI, 1.20-1.75), and unintentional deaths (adjusted IRR, 9.32; 95% CI, 2.32-37.4). The PAF was 0.51 (95% CI, 0.43-0.57) for all firearm-related deaths, 0.66 (95% CI, 0.57-0.73) for homicides, 0.30 (95% CI, 0.17-0.42) for suicides, and 0.86 (95% CI, 0.46-0.97) for unintentional deaths. This calculation translated to 34 292 firearm-related deaths that would not have occurred if all counties had the same risk as counties with the lowest poverty concentration. A total of 3 833 105 years of potential life lost was observed.
Conclusions and Relevance
This study found an association between firearm-related mortality rates among youth and county-level poverty concentration. With more than half of firearm-related deaths and two-thirds of firearm-related homicides potentially associated with living in an area with a high concentration of poverty, a multidimensional strategy to reduce poverty and firearm-related deaths is urgently needed.
... These civil orders provide a process for temporary removal of firearms from individuals who threaten imminent violence against themselves or others. State-level studies suggest ERPOs may prevent firearm suicides (Kivisto and Phalen 2018;Swanson et al. 2019;Swanson, et al. 2017), and there are documented cases where ERPOs have been used to prevent mass shootings . Importantly, ERPOs are not intended to target or stigmatize individuals living with mental illness, but rather those who pose a specific risk of violence. ...
Background
Extreme Risk Protection Orders (ERPOs) are a relatively new type of law that are being considered or implemented in many states in the United States. Colorado’s law went into effect on January 1, 2020, after significant controversy and concern over potential misuse of the law to confiscate weapons; many ( n = 37 of 64) counties declared themselves “2nd Amendment (2A) sanctuaries” and said they would not enforce the law. Here, reviewed the patterns of use of the law during its first year.
Methods
We obtained all court records for ERPO petitions filed between January 1 and December 31, 2020. Data elements were abstracted by trained staff using a standardized guide. We calculated the proportion of petitions that were approved or denied/dismissed, identified cases of obvious misuse, and examined patterns by 2A county status.
Finding and results
In 2020, 109 ERPO petitions were filed in Colorado; of these, 61 were granted for a temporary ERPO and 49 for a full (year-long) ERPO. Most petitions filed by law enforcement officers were granted (85%), compared to only 15% of petitions filed by family or household members. Of the 37 2A sanctuary counties, 24% had at least one petition filed, versus 48% of non-2A sanctuary counties. Across the 2A counties, there were 1.52 ERPOs filed per 100,000 population, compared to 2.05 ERPOs filed per 100,000 in non-2A counties. There were 4 cases of obvious law misuse; none of those petitions resulted in an ERPO or firearm confiscation.
Conclusion
State-level studies suggest ERPOs may prevent firearm injuries. Robust implementation, however, is critical for maximal effect. Understanding ERPO experiences and challenges can inform policy creation and enaction in other states, including identifying how best to address concerns and facilitate evaluation.
... " Generally, ERPOs provide an individualized tool for temporary removal of firearm(s) and prohibition on purchase for individuals who pose a risk to self or others but who have not committed an offense prohibiting them from possession or purchase and for whom other interventions for risk reduction have been exhausted or are not appropriate. In Connecticut, such a law has been shown to be effective for suicide prevention, with an estimated one suicide prevented for every 10-20 firearm removal actions [90,91]. In many states, law enforcement, family, and household members can petition for ERPOs. ...
Suicide is complex, with psychiatric, cultural, and socioeconomic roots. Though mental illnesses like depression contribute to risk for suicide, access to lethal means such as firearms is considered a key risk factor for suicide, and half of suicides in the USA are by firearm. When a person at risk of suicide has access to firearms, clinicians have a range of options for intervention. Depending on the patient, the situation, and the access to firearms, counseling on storage practices, temporary transfer of firearms, or further intervention may be appropriate. In the USA, ownership of and access to firearms are common and discussing added risk of access to firearms for those at risk of suicide is not universally practiced. Given the burden of suicide (particularly by firearm) in the USA, the prevalence of firearm access, and the lethality of suicide attempts with firearms, we present the existing evidence on the burden of firearm suicide and what clinicians can do to reduce their patients’ risk. Specifically, we review firearm ownership in the USA, firearm injury epidemiology, risk factors for firearm-related harm, and available interventions to reduce patients’ risk of firearm injury and death.
... 31 Policy efforts such as red flag laws, which allow court petitions to temporarily prohibit firearm purchase and possession to individuals deemed dangerous to self or others, have broad public support and are associated with modest reductions in firearm suicide rates. 44 However, a substantial proportion of the period effect in firearm suicide mortality could not be explained by rates and trends in household firearm ownership. There was a notable increase in firearm suicide mortality risk among recent birth cohorts, in line with recent research 14 and consistent with recent increases in depression and suicidal behaviors among U.S. adolescents and young adults. ...
Introduction
In the U.S., state-level household firearm ownership is strongly associated with firearm suicide mortality rates. Whether the recent increases in firearm suicide are explained by state-level household firearm ownership rates and trends remains unknown.
Methods
Mortality data from the U.S. National Vital Statistics System and an estimate of state-level household firearm ownership rate were used to conduct hierarchical age–period–cohort (random-effects) modeling of firearm suicide mortality between 2001 and 2016. Models were adjusted for individual-level race and sex and for state-level poverty rate, unemployment rate, median household income in U.S. dollars, population density, and elevation.
Results
Between 2001 and 2016, the crude national firearm suicide mortality rate increased from 6.8 to 8.0 per 100,000, and household firearm ownership rate remained relatively stable, at around 40%. Both variables were markedly heterogeneous and correlated at the state level. Age–period–cohort models revealed period effects (affecting people across ages) and cohort effects (affecting specific birth cohorts) underlying the recent increases in firearm suicide. Individuals born after 2000 had higher firearm suicide rates than most cohorts born before. A 2001–2006 decreasing period effect was followed, after 2009, by an increasing period effect that peaked in 2015. State-level household firearm ownership rates and trends did not explain cohort effects and only minimally explained period effects.
Conclusions
State-level firearm ownership rates largely explain the state-level differences in firearm suicide but only marginally explain recent increases in firearm suicide. Although firearms in the home increase firearm suicide risk, the recent national rise in firearm suicide might be the result of broader, more distal causes of suicide risk.
... ERPOs provide law enforcement with the ability to temporarily remove or restrict firearms from a person at risk of harming themselves or others. Firearm removal during crisis situations provides a critical cooling-off period and time for mental health intervention or law enforcement investigation. 2 Previous research found that firearm removal orders have deterred firearm suicides, 3,4 reduced the risk of domestic partner homicide, 5 and may prevent mass shootings. 6 On the basis of these outcomes, in April 2021, President Biden urged Congress to pass a national ERPO law and legislation incentivizing states to pass ERPOS laws of their own. ...
... [31][32][33][34][35] Unfortunately, enforcement of GVROs can been variable and some states and jurisdictions may enforce GVROs more heavily than others. 36,37 A recent longitudinal study showed that GVROs could be effective in decreasing suicides in elderly males; the same population that we found to be highest risk in our study. 38 More prospective studies that can comprehensively compare gun legislation, suicide screening programs, and GVROs as interventions in different regions, counties, states in the U.S should be performed to investigate the effectiveness of these strategies in the prevention of firearm suicides. ...
Introduction:
Intentional self-harm (suicide) by firearms is a growing problem in the United States. Currently, there are no large studies that have identified risk factors for patients who die from self-inflicted gunshot wounds. Our objectives are to 1) identify risk factors for patients with the highest morbidity and mortality from self-inflicted gunshot wounds (SIGSWs) at trauma centers 2) present the outcomes of victims of SIGSW by handguns (HG) versus all other specified guns (AOG) and 3) compare the presentations and outcomes of victims with head or face (HF) injuries to other regions of the body.
Methods:
We performed a retrospective analysis from the National Trauma Database (NTDB) data between 2012 and 2013 of all SIGSW patients who presented to trauma centers. Categorical data included patient characteristics upon presentation and outcomes which were compared between patients with HG injury versus AOG injury using the Chi-Squared test, where AOG includes shotguns, hunting rifles, and military firearms. Additionally, analysis of head and face (HF) injuries versus other bodily injuries (OBI) were compared between the HG group versus AOG group using Chi-squared test.
Results:
There were 7,828 SIGSWs, of those, 78% (6,115) were white and 84.3% (6,600) were male. There were 5,139 HG injuries, 1,130 AOG injuries, and 1,405 unidentified gun injuries. The HG group was likely to be older (>55 years old), hypotensive (systolic blood pressure < 90), have a lower Glasgow Coma Score (GCS < 9), use illegal, or use prescription drugs. In comparing HF injuries (4,799) versus other bodily injuries (OBI) (3,028), HF group was more likely to use handguns, expire in ED, require ICU, and have a higher percent of overall mortality. Of the total OBI, the thorax, upper extremities, and abdomen were the most commonly injured.
Conclusion:
In our retrospective study of SIGSWs, we were able to demonstrate that SIGSW by handguns are associated with higher rates of mortality versus all other types of firearms. SIGSWs in older white males with handguns are the most at-risk for severe complications. Future efforts should improve screening methods for handguns in suicidal patients and at developing prevention programs.
... A possible explanation for our results might be that people with mental disorders have less access or more obstacles to obtain firearms (Kaplan et al., 2009). Some states in the US, such as Indiana or Connecticut (Kivisto, 2018), which have background checks for both criminal history and mental illness, tend to have lower firearm suicide rates than states which only implement criminal history checks (Sen and Panjamapirom, 2012;Sumner et al., 2008). Other studies showed that individuals with mental disorders were no more or less likely to have access to firearms than others without mental disorders (Ilgen et al., 2008;Swanson et al., 2015). ...
Background:
In the United States (US), 61% of all suicide cases may involve firearms, and some evidence suggests that mental disorders may play a role in suicide by firearm. We performed the first systematic review and meta-analyses to investigate: (i) whether mental disorders are associated with suicide by firearm, and (ii) whether the risk of using a firearm compared with alternative means is associated with higher levels of suicide in individuals with a mental disorder METHODS AND FINDINGS: We searched twelve databases from inception to the 24th of May 2020. We retrieved 22 observational studies conducted in the US. Random-effects meta-analyses showed individuals who had a diagnosis of a mental disorder had lower odds (odds ratios (OR)= 0.50, 95% CI: 0.36 to 0.69; I2=100 (95% CI: 87 to 100%), of dying by suicide with a firearm than those who did not have a diagnosis of a mental disorder. Secondary analysis showed that decedents who had a mental health diagnosis resulted in lower odds of dying by suicide by using firearms than using other means LIMITATIONS: Risk of bias revealed a heterogeneous and poor definition of mental disorders as well as lack of control for potential demographic confounding factors. In the meta-analyses, studies were combined in the same analytic sample as 77% of these studies did not specify the type of mental disorder CONCLUSION: While our results seem to suggest that having a mental disorder may not be consistently associated with the odds of dying by suicide using a firearm, the presence of substantial heterogeneity and high risk of bias precludes any firm conclusions.
... Red flag laws, properly known as extreme risk protection orders, or ERPOs, allow family members to petition a court to temporarily remove a person's access to firearms if they pose a threat to themselves or others. Evidence suggests they are an effective suicide and domestic violence prevention tool (Kivisto & Phalen, 2018;Swanson et al., 2017;Zeoli & Paruk, 2020); it would appear they might help reduce mass shootings as well (see Laqueur & Wintemute, 2020). ...
Mass shootings are often blamed on serious mental illness. This study assesses the role of psychosis in contributing to mass shootings along a continuum. The role of psychosis is compared with other motiva- tions for mass shootings including employment issues, interpersonal conflict, relationship issues, hate, and fame-seeking. Perpetrators motivated by psychosis are also compared with other perpetrators on several well-established risk factors for violence. It is hypothesized that a mental health history is com- mon among mass shooters, but symptoms of psychosis only directly motivate mass shootings for a mi- nority of cases. A dataset of 172 mass shooters was created, coded on 166 life history variables using publicly available data. The entire dataset and codebook are publicly available. The findings show that symptoms of psychosis played no role in 69% of cases, but psychosis may have played a minor role in 11% of cases, a moderate role in 9% of cases, and a major role in 11% of cases. Perpetrators motivated by psychosis were similar to mass shooters with other motivations in terms of demographics and com- mon risk factors for violence. The role of serious mental illness in mass shootings is complex. The data indicate that access to mental health care may help prevent mass shootings in a minority of cases, but this is far from the only solution to mass shootings.
Firearm violence is the leading cause of death in children and adolescents in the United States, impacting children of all socioeconomic status, race, and ethnicity, though with significant burden in minority populations. Pediatricians have a unique role in prevention of firearm injury and mortality through intervention, education, and advocacy. Specifically, pediatricians can screen to identify those at risk, counsel patients and families to prevent firearm injuries, work within local communities to improve targeted intervention strategies, and participate in national advocacy groups. By taking a personal responsibility and a public health approach, pediatric health care providers play a pivotal in decreasing the burden of firearm injury, mortality, and adherence to gun safety.
Importance
Extreme risk protection orders (ERPOs)—also known as red flag, risk warrant, and gun violence restraining orders—authorize law enforcement, family members, and sometimes others to petition a court to remove firearms from and prevent the acquisition of new firearms by a person judged to pose an immediate danger to themselves or others. Previous estimates suggest that 1 suicide is prevented for every 10 ERPOs issued, a number needed to treat that depends critically on the counterfactual estimate of the proportion of suicidal acts by ERPO respondents that would have involved firearms in the absence of ERPOs.
Objective
To empirically inform updated estimates of the number of ERPOs needed to prevent 1 suicide.
Design, Setting, and Participants
This cohort study used data from California for method-specific suicides by handgun ownership (October 18, 2004, to December 31, 2015). Handgun-owning suicide decedents in California were identified using individual-level registry data about lawful handgun ownership linked to cause-specific mortality for a cohort of more than 25 million adults. The study also used data from Connecticut for method-specific suicides among ERPO respondents who died by suicide, extracted from published data (October 1999 to June 2013). Data analysis was performed in December 2023.
Exposure
Handgun ownership.
Main Outcomes and Measures
The primary outcomes were the number and distribution of suicidal acts by handgun owners in California, estimated using method-specific suicide mortality data and published case fatality ratios, and the counterfactual number and distribution of suicidal acts and deaths among ERPO respondents in Connecticut had no ERPOs been issued.
Results
A total of 1216 handgun owners (mean [SD] age, 50 [18] years; 1019 male [83.8%]) died by suicide during the study period. Among male handgun owners in California, 28% of suicidal acts involved firearms, 54% involved drug poisoning, 9% involved cutting or piercing, 3% involved hanging or suffocation, 2% involved poisoning with solids and/or liquids, and the remaining 4% involved other methods. Assuming this distribution approximates the counterfactual distribution among ERPO respondents in Connecticut in the absence of ERPOs, 1 suicide death was prevented for every 22 ERPOs issued.
Conclusions and Relevance
The estimates produced by this cohort study of California handgun owners suggest that ERPOs can play an important role in averting deaths among high-risk individuals.
In 2022 we conducted a literature review, surveyed 1078 gun owners, and conducted post-survey focus groups and interviews of gun owners and non-gun owners, to determine a common ground gun violence prevention (GVP) policy package. This allowed us to see policies that would save lives and be widely accepted: (1) violent misdemeanor laws, (2) state permit laws, combined with universal background checks; (3) red flag laws. Based on our review of relevant research, we conservatively estimate that in states without any of the policy package components, implementing this package would result in a 27.9% reduction in firearm deaths. We believe that polarization between firearm owners and non-firearm owners, which has thwarted a widely supported response to the problem of gun violence, is largely a harmful myth that can be overcome by including gun owners in the process of fashioning an effective policy approach.
Extreme Risk Protection Order (ERPO) laws have received increasing attention as a tool to prevent firearm suicide and homicide, including mass shootings. However, important gaps remain in our understanding of ERPO usage and implementation. Using the Oregon Judicial Case Information Network database, we abstracted data from all ERPO petitions filed in Oregon from 2018 to 2022, the first five years after the law took effect ( N = 649). ERPO petitions were filed in 29 of 36 counties (81%, range 0–105 per county, median 11), against respondents 17–96 years of age (median: 42). Of ERPOs filed, 78% were initially granted. While only 22% of respondents in initially-granted ERPOs requested a hearing, when a hearing was held, nearly half (44%) of ERPOs were dismissed. The majority of ERPO petitions were motivated by threats of harm to respondents and others ( n = 327, 50%), followed by threats of harm to others-only ( n = 220, 34%) or respondents-only ( n = 81, 12%). During the 5-year period, 72 (11%) ERPO petitions cited threats of mass violence as a motivating factor, including 24 (4%) petitions citing threats to schools or college campuses. The majority of ERPOs were filed by law enforcement officers (60%), and these petitions were significantly more often granted than those filed by family/household members (96% vs. 67%, p < .0001). We also found evidence of important gaps in documentation, including of respondent race (unavailable for 191 respondents, 29%) and of weapon removal or disposition after the ERPO was granted (unavailable in 350 cases, 69%). This study of long-term patterns of ERPO petitions highlights trends in usage and suggests areas where improvement may be possible, with implications for other states that have adopted or are considering similar ERPO laws.
Importance
Understanding knowledge of, attitudes toward, and willingness to use extreme risk protection order (ERPO) laws among law enforcement officers (LEOs) can inform efforts to improve implementation of this underused firearm violence prevention strategy.
Objective
To characterize LEOs’ knowledge of, attitudes toward, and willingness to use ERPOs across a range of scenarios.
Design, Setting, and Participants
A cross-sectional online survey, fielded from April 5 to August 30, 2021, was conducted in all 19 states and the District of Columbia with an ERPO law in 2021. A nonprobability sample of active-duty LEOs was used.
Exposure
Being a LEO in a state with an ERPO law.
Main Outcomes and Measures
Survey participants answered questions about their familiarity with and opinions on ERPO laws, as well as whether they would agree with using an ERPO in a variety of specific case scenarios. The analysis included an exploration of whether within-scenario differences, such as ERPO respondent race or gender, affected agreement by randomly assigning survey participants to 1 of 2 versions of each scenario.
Results
A total of 600 eligible individuals started the survey, and 283 survey participants were included in the analysis. The analytic sample consisted mostly of cisgender men (85.2%) and non-Hispanic White (71.4%) LEOs. Participants represented 14 states and the District of Columbia, with 53.7% living in California. Most participants (81.3%) were very or somewhat familiar with ERPO laws and 56.2% had received ERPO training. Opinions about ERPO laws were generally favorable but varied by self-identified political ideology. Across all scenarios, most participants supported using an ERPO; however, support was highest in cases involving intimate partner violence (71.4%-78.6%) and lowest in cases involving suicidality (54.2%-73.3%). Across all scenarios, LEOs with ERPO training or experience were substantially more likely to agree with using ERPOs than those without. None of the randomly assigned within-scenario differences were associated with differences in ERPO support.
Conclusions and Relevance
In this survey study of LEOs in states with ERPO laws, many officers had not received training on their use. Additionally, while conservative political ideology was associated with less favorable views of ERPOs, training and experience with ERPOs was associated with greater support for their use across a range of scenarios. These findings suggest that LEO training on ERPOs may promote their uptake and improve implementation.
The suicide rate in the United States has risen nearly 40% since 2000. This increase is puzzling because suicide rates had been falling for decades at the end of the 20th century. In this paper, we review important facts about the changing rate of suicide. General trends do not tell the story of important differences across groups—suicide rates rose substantially among middle‐aged persons between 2005 and 2015 but have fallen since. Among young people, suicide rates began a rapid rise after 2010 that has not abated. We review empirical evidence to assess potential causes for recent changes in suicide rates. The economic hardship caused by the Great Recession played an important role in rising suicide among prime‐aged Americans. Among those under 25, nearly all the increase in suicide mortality during the 2010s can be explained by an increase in the prevalence of depression. Bullying victimization of LGBTQ youth could also account for part of the rise in suicide. The evidence that access to firearms or opioids are major drivers of recent suicide trends is less clear. We end by summarizing evidence on the most promising policies to reduce suicide mortality.
We present the rationale behind four types of laws that restrict access to firearms for those who are deemed to be a high risk for future gun violence and two types of laws that implement firearm purchase prohibitions. We also present evidence on the effectiveness of these laws. Broadly, these are laws that restrict access for domestic violence abusers, individuals convicted of misdemeanor violence, and individuals at high risk of violence against themselves or others. We briefly discuss relinquishment of firearms by those who are newly restricted, but we focus mainly on how purchase restrictions are implemented by the federal government and across states. Extant research shows that well-implemented firearm policy that is based on evidence-based risk factors can be effective in reducing firearm injury.
Colorado has consistently had one of the highest rates of suicide in the United States, and El Paso County has the highest number of suicide and firearm-related suicide deaths within the state. Community-based solutions like those of the Suicide Prevention Collaborative of El Paso County may be more effective in preventing suicide as they are specific to local issues, sensitive to local culture, and informed by local data, community members, and stakeholders.
Extreme risk protection orders (ERPOs), which allow for the temporary restriction of firearm access for individuals at substantial risk of harming themselves and/or others, are a promising policy tool to address increasing rates of firearm-related suicide, homicide, and mass shootings. Social workers frequently assess clients at risk of firearm-related harm, positioning social workers to play a key role in ERPO implementation. This study sought to understand social workers’ perspectives on ERPOs. Authors invited 6,910 licensed social workers in Washington state to participate in a survey in May and June of 2021 about facilitators and barriers to their willingness to counsel clients’ family members, contact law enforcement, or independently file ERPOs for clients at risk of harm to self (HTS) or others (HTO). Of the 1,381 survey participants, most were willing to counsel (96 percent for HTS; 96 percent HTO), contact law enforcement (84 percent for HTS; 87 percent for HTO), or independently file an ERPO (78 percent for HTS; 79 percent for HTO). Common barriers associated with willingness were lack of understanding about the ERPO process and concerns with involving the legal system/law enforcement. Key facilitators included training social workers about ERPOs and availability of legal experts for consultations. Social workers are willing to incorporate ERPOs into their practice for clients, but remaining barriers need to be addressed to support the practice.
Firearms are the leading cause of death in children and youth 0 to 24 years of age in the United States. They are also an important cause of injury with long-term physical and mental health consequences. A multipronged approach with layers of protection focused on harm reduction, which has been successful in decreasing motor vehicle-related injuries, is essential to decrease firearm injuries and deaths in children and youth. Interventions should be focused on the individual, household, community, and policy level. Strategies for harm reduction for pediatric firearm injuries include providing anticipatory guidance regarding the increased risk of firearm injuries and deaths with firearms in the home as well as the principles of safer firearm storage. In addition, lethal means counseling for patients and families with individuals at risk for self-harm and suicide is important. Community-level interventions include hospital and community-based violence intervention programs. The implementation of safety regulations for firearms as well as enacting legislation are also essential for firearm injury prevention. Increased funding for data infrastructure and research is also crucial to better understand risks and protective factors for firearm violence, which can then inform effective prevention interventions. To reverse this trend of increasing firearm violence, it is imperative for the wider community of clinicians, public health advocates, community stakeholders, researchers, funders, and policy makers to collaboratively address the growing public health crisis of firearm injuries in US youth.
Objective:
To analyze differences in the demographic and social factors associated with pregnancy-associated violent deaths due to homicide compared with suicide by pregnancy timing.
Methods:
This was a retrospective cohort study using the Centers for Disease Control and Prevention's National Violent Death Reporting System from 2008 to 2019. We included females aged 15-44 years who died by suicide, defined as intentional self-harm, or homicide. Pregnancy-associated deaths were defined as those that occurred during or within 1 year of pregnancy.
Results:
Of 38,417 female victims aged 15-44 years identified in the data set, 10,411 had known pregnancy status; 1,300 of those deaths were pregnancy associated. Of all deaths with known pregnancy status, 3,203 were by homicide (30.8%) and 7,208 (69.2%) were by suicide. Pregnancy-associated homicide deaths made up 20.6% of all homicide deaths, and pregnancy-associated suicide deaths made up 8.8% of all suicide deaths. Individuals who died by homicide were younger (29.4±8.2 years vs 31.5±8.6 years), more likely to be single or never married (61.0% vs 50.0%), and had a higher proportion of associate's degree-level education or less as compared with individuals who died by suicide (28.1% vs 43.9%). Of individuals who died by homicide, 37.7% were Black or African American, 13.4% were Hispanic, and 56.0%% were White. In comparison, 6.9% of individuals who died by suicide were Black or African American, 8.0% were Hispanic, and 85.0% were White. Having a mental health problem and any substance use were significantly more often associated with suicide deaths compared with homicide deaths (77.4% vs 7.2%, P<.001 for mental health, 33.3% vs 12.8%, P<.001 for substance use, respectively). Intimate partner violence was prevalent in both groups, although significantly higher in homicide deaths (57.3% vs 37.1%, P<.001). This pattern persisted when stratified by pregnancy status.
Conclusion:
Mental health problems, substance use disorder, and intimate partner violence are preceding circumstances to pregnancy-associated suicide and homicide.
Extreme risk protection orders (ERPOs) provide a civil mechanism to temporarily remove firearm access from individuals at high risk of harming themselves or others. Evidence and theory suggest that ERPOs can prevent firearm-related harm, but the policy's impact on racial/ethnic equity is largely unknown. To examine potential inequities by race/ethnicity in public perceptions and use of California's ERPO law, we drew on two complementary data sources: 1) a 2020 state-representative survey of California adults, and 2) ERPO court documents for the first 3 years of policy implementation (2016–2018). Majorities (54–89%) of all racial/ethnic groups reported that ERPOs are at least sometimes appropriate, and 64–94% were willing to ask a judge for an ERPO for a family member. However, Black and Hispanic/Latinx survey participants less often perceived ERPOs as appropriate and were less willing to serve as petitioners, with Black participants citing lack of knowledge about ERPOs and not trusting the system to be fair as their top reasons for unwillingness. Similarly, review of ERPO court documents revealed that no family or household members served as petitioners for Black and Hispanic/Latinx ERPO respondents, and these respondents were the most likely to be arrested in conjunction with the ERPO. Additionally, Black respondents were the least likely to have documented access to a firearm and legal representation in court. Racial/ethnic equity in ERPO use may be improved by reducing barriers to petitioning, incorporating non-law enforcement intervention professionals like behavioral health specialists into the ERPO process, providing legal assistance to respondents and petitioners, and investing in the social safety net.
Purpose of Review
Firearm policies have the potential to alleviate the public health burden of firearm violence, yet it is unclear which policies are effective. The current review aims to summarize studies that use synthetic control methods to overcome previous methodological limitations when examining the impacts of firearm policies.
Recent Findings
Evidence from studies using synthetic control methods find compelling evidence that purchasing licensing laws for all individuals (e.g., permit-to-purchase) have a preventive effect on firearm deaths. Otherwise, the effects of other firearm policies targeting firearm availability, ownership, sales, and use varied across studies and contexts.
Summary
Synthetic control evaluations find heterogenous effects of firearm policies, suggesting that previous inconsistent findings might reflect their varying impacts across regions rather than methodological limitations alone. Future research should aim to exploit the complementary biases of synthetic control methods to triangulate evidence across evaluation approaches and understand why firearm policies have differential impacts.
Importance:
California's gun violence restraining order (GVRO) law, implemented beginning in 2016, allows for people at high risk of harming themselves or others with a firearm to be temporarily disarmed and prevented from purchasing firearms for 3 weeks to 1 year; many states have recently enacted similar laws. The research to date is on older and more limited risk-warrant laws.
Objective:
To determine whether implementation of the California GVRO law was associated with decreased rates of firearm assault or firearm self-harm in a large metropolitan county between 2016 and 2019.
Design, setting, and participants:
This serial cross-sectional study including data from 28 counties used the synthetic control method to evaluate differences in firearm violence between San Diego County and its synthetic control following implementation of the California law from 2016 to 2019. San Diego County was used as the treated unit because it issued substantially more GVROs than any other county in California during the study period. A total of 27 California counties that issued no or very few gun violence restraining orders from 2016 to 2019 and that had stable rates of firearm violence between 2005 and 2015 were included in the control pool. Data were analyzed from February 2021 to July 2021.
Exposures:
Implementation of the statewide GVRO law in 2016 in San Diego County.
Main outcomes and measures:
Annual rates of fatal and nonfatal firearm assault injuries and firearm self-harm injuries per 100 000 people.
Results:
In the study period, there were 355 GVROs in San Diego county, and a median (IQR) total of 8 (3-20) GVROs per donor county. The mean difference between the observed rate in San Diego County and the estimated rate in the synthetic San Diego County, 2016-2019, was -0.74 firearm assaults per 100 000 (-13% difference) and 0.13 firearm self-harm injuries per 100 000 (3% difference). Results from in-space placebo tests suggested that these differences cannot be distinguished from variation due to chance (pseudo-P values from a 1-sided test: P for assault = .35, P for self-harm = .67).
Conclusions and relevance:
To our knowledge, this study was the first to analyze the association between GVRO implementation and firearm violence in California and the first to evaluate the association between risk-based firearm removal laws and firearm assault in any state. GVROs were not associated with reduced population-level rates of firearm violence in San Diego County, but this may change as the number of orders increases over time; the association between GVROs and firearm violence at the individual level cannot be inferred from our findings and should be the subject of future studies.
Research Summary
Risk-based firearm removal policies are relatively new, and research on their implementation and effectiveness is limited. Using an interpretive phenomenological approach, we interviewed stakeholders in California's gun violence restraining order (GVRO) process to learn about circumstances in which GVROs are appropriate. Two primary themes emerged: (1) GVROs are most useful when there is acute risk of harm with a firearm, in the context of cognitive decline, or as related cases proceed through the courts, and (2) GVROs fill a gap in the policy landscape. Perceptions varied regarding the role of GVROs among preexisting violence prevention tools. Several informants perceived racial/ethnic disparities in GVRO use.
Policy Implications
Understanding practitioners’ perceptions of GVRO utility may help inform implementation and ensure that these policies equitably improve public health and safety. These results highlight the need for additional research on the impact of GVROs and possible disparities in use.
While gun violence continues to be a leading killer of U.S. children and adolescents, there remains little evidence-based public policy directed at this epidemic, a disparity largely stemming from the 1996 National Rifle Association-supported Dickey Amendment. Though the federal government has only recently begun funding public policy research on gun violence prevention, available data suggest that pediatric firearm morbidity and mortality are impacted by specific policies. This chapter will review those policies including child access prevention, extreme risk protection orders, minimum age requirements, mandatory waiting periods, universal background checks, campus carry restrictions, and stand-your-ground laws.
Suicide is a major public health concern in the United States. Between 2000 and 2018, US suicide rates increased by 35%, contributing to the stagnation and subsequent decrease in US life expectancy. During 2019, suicide declined modestly, mostly owing to slight reductions in suicides among Whites. Suicide rates, however, continued to increase or remained stable among all other racial/ethnic groups, and little is known about recent suicide trends among other vulnerable groups. This article ( a) summarizes US suicide mortality trends over the twentieth and early twenty-first centuries, ( b) reviews potential group-level causes of increased suicide risk among subpopulations characterized by markers of vulnerability to suicide, and ( c) advocates for combining recent advances in population-based suicide prevention with a socially conscious perspective that captures the social, economic, and political contexts in which suicide risk unfolds over the life course of vulnerable individuals.
Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
Suicide accounts for approximately 4000 deaths a year in Canada, of which about 16% of those are suicide using a firearm. Canada has undertaken legislative efforts to regulate and control firearms, Bill C-51 in 1977 and Bills C-17 and C-68 in 1991 and 1995. Regulatory approaches that decrease the availability of firearms are hypothesized to reduce suicide by firearm however the substitution effect suggests it is possible that people may substitute other methods of suicide in place. Canadian studies on associations between legislation, regulation, and suicide rates have been published over the last three decades, and a search revealed thirteen that met the criteria. Seven studies examined the association between Bill C-51 and suicide rates and found that while rates of suicide by firearm appeared to have declined in association with regulations, there appears to be a substitution effect into other methods and no overall change in suicide rates. Six studies examining the effects of Bill C-17 and C-68 revealed a decrease in the rates of suicide by firearms, with a corresponding increase in non-firearms suicide rates and no decrease in overall suicide rates. One study even suggested no associated decrease in firearm suicide rates with an increasing rate of suicide by hanging possibly due to changes in preferences. These results suggest legislation has mixed effects on firearm suicide rates and may not alone reduce overall suicide in Canada.
Research Summary
We examined petition and respondent characteristics from extreme risk protection order (ERPO) cases in Oregon for the 15 months after implementation (n = 93). Most petitions were filed by law enforcement (65%) a were more likely to be granted than petitions filed by family/household members (p < 0.001). Most ERPO respondents were reported by petitioners to have histories of suicidality (73%) or interpersonal violence (75%), with over half of death threats, suicide threats, or suicide attempts with known timing occurring within 1 week of the petition being filed.
Policy Implications
ERPO petitions and orders are overwhelmingly being used as intended, that is, specifically for cases of imminent risk of harm to self or others. Greater dissemination of public information about ERPOs may increase their appropriate use and the proportion of high‐risk individuals and families who may benefit. Legal aid assistance for family or household members in filling out petitions is advisable.
Randomization inference or permutation tests are only sporadically used in economics and other social sciences—this despite a steep increase in randomization in field and laboratory experiments that provide perfect experimental setups for applying randomization inference. In the context of causal inference, such tests can handle problems often faced by applied researchers, including issues arising in the context of small samples, stratified or clustered treatment assignments, or nonstandard randomization techniques. Standard statistical software packages have either no implementation of randomization tests or very basic implementations. Whenever researchers use randomization inference, they regularly code individual program routines, risking inconsistencies and coding mistakes. In this article, I show how randomization inference can best be conducted in Stata and introduce a new command, ritest, to simplify such analyses. I illustrate this approach’s usefulness by replicating the results in Fujiwara and Wantchekon (2013, American Economic Journal: Applied Economics 5: 241–255) and running simulations. The applications cover clustered and stratified assignments, with varying cluster sizes, pairwise randomization, and the computation of nonapproximate p-values. The applications also touch upon joint hypothesis testing with randomization inference.
In recent years a widespread consensus has emerged about the necessity of establishing bridges between the quantitative and the qualitative approaches to empirical research in political science. In this article, we discuss the use of the synthetic control method (Abadie and Gardeazabal, 2003; Abadie, Diamond, and Hainmueller, 2010) as a way to bridge the quantitative/qualitative divide in comparative politics. The synthetic control method provides a systematic way to choose comparison units in comparative case studies. This systematization opens the door to precise quantitative inference in small-sample comparative studies, without precluding the application of qualitative approaches. That is, the synthetic control method allows researchers to put "qualitative flesh on quantitative bones"' (Tarrow, 1995). We illustrate the main ideas behind the synthetic control method with an application where we study the economic impact of the 1990 German reunification in West Germany.
The R package Synth implements synthetic control methods for comparative case studies designed to estimate the causal e ects of policy interventions and other events of interest (Abadie and Gardeazabal 2003; Abadie, Diamond, and Hainmueller 2010). These techniques are particularly well-suited to investigate events occurring at an aggregate level (i.e., countries, cities, regions, etc.) and a ffecting a relatively small number of units.
Bene ts and features of the Synth package are illustrated using data from Abadie and
Gardeazabal (2003), which examined the economic impact of the terrorist conflict in the Basque Country.
Building on an idea in Abadie and Gardeazabal (2003), this article investigates the application of synthetic control methods to comparative case studies. We discuss the advantages of these methods and apply them to study the effects of Proposition 99, a large-scale tobacco control program that California implemented in 1988. We demonstrate that following Proposition 99 tobacco consumption fell markedly in California relative to a comparable synthetic control region. We estimate that by the year 2000 annual per-capita cigarette sales in California were about 26 packs lower than what they would have been in the absence of Proposition 99. Given that many policy interventions and events of interest in social sciences take place at an aggregate level (countries, regions, cities, etc.) and affect a small number of aggregate units, the potential applicability of synthetic control methods to comparative case studies is very large, especially in situations where traditional regression methods are not appropriate. The methods proposed in this article produce informative inference regardless of the number of available comparison units, the number of available time periods, and whether the data are individual (micro) or aggregate (macro). Software to compute the estimators proposed in this article is available at the authors' web-pages.Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.
This study examined incidence rates of medically identified suicide acts (self-inflicted injuries, either fatal or nonfatal) and case fatality rates by age, sex, race, and method used.
The authors analyzed data on 10,892 suicides and 57,439 attempted suicides among hospital-admitted individuals in 8 states, along with 6219 attempted suicides among individuals released from emergency departments in 2 states.
The 8 states experienced a mean of 11 suicides and 119 attempted suicides per 100,000 residents each year. Groups with high suicide rates were men, the elderly, and Whites; groups with high attempted suicide rates were teenagers, young adults, women, and Blacks and Whites aged 25 to 44 years. Blacks aged 15 to 44 years evidenced high attempted suicide rates undocumented in previous studies. Poisoning and firearm were the most common methods used among those attempting suicide and those completing suicide acts, respectively. The most lethal method was firearm.
The characteristics of suicides and attempted suicides differ dramatically. Method used is important in the lethality of the act.
Suicide risk was addressed in relation to the joint effect of factors regarding family structure, socioeconomics, demographics, mental illness, and family history of suicide and mental illness, as well as gender differences in risk factors.
Data were drawn from four national Danish longitudinal registers. Subjects were all 21,169 persons who committed suicide in 1981-1997 and 423,128 live comparison subjects matched for age, gender, and calendar time of suicide by using a nested case-control design. The effect of risk factors was estimated through conditional logistic regression. The interaction of gender with the risk factors was examined by using the log likelihood ratio test. The population attributable risk was calculated.
Of the risk factors examined in the study, a history of hospitalization for psychiatric disorder was associated with the highest odds ratio and the highest attributable risk for suicide. Cohabiting or single marital status, unemployment, low income, retirement, disability, sickness-related absence from work, and a family history of suicide and/or psychiatric disorders were also significant risk factors for suicide. Moreover, these factors had different effects in male and female subjects. A psychiatric disorder was more likely to increase suicide risk in female than in male subjects. Being single was associated with higher suicide risk in male subjects, and having a young child with lower suicide risk in female subjects. Unemployment and low income had stronger effects on suicide in male subjects. Living in an urban area was associated with higher suicide risk in female subjects and a lower risk in male subjects. A family history of suicide raised suicide risk slightly more in female than in male subjects.
Suicide risk is strongly associated with mental illness, unemployment, low income, marital status, and family history of suicide. The effect of most risk factors differs significantly by gender.
Background:
Difference-in-differences (DID) estimation has become increasingly popular as an approach to evaluate the effect of a group-level policy on individual-level outcomes. Several statistical methodologies have been proposed to correct for the within-group correlation of model errors resulting from the clustering of data. Little is known about how well these corrections perform with the often small number of groups observed in health research using longitudinal data.
Methods:
First, we review the most commonly used modeling solutions in DID estimation for panel data, including generalized estimating equations (GEE), permutation tests, clustered standard errors (CSE), wild cluster bootstrapping, and aggregation. Second, we compare the empirical coverage rates and power of these methods using a Monte Carlo simulation study in scenarios in which we vary the degree of error correlation, the group size balance, and the proportion of treated groups. Third, we provide an empirical example using the Survey of Health, Ageing, and Retirement in Europe.
Results:
When the number of groups is small, CSE are systematically biased downwards in scenarios when data are unbalanced or when there is a low proportion of treated groups. This can result in over-rejection of the null even when data are composed of up to 50 groups. Aggregation, permutation tests, bias-adjusted GEE, and wild cluster bootstrap produce coverage rates close to the nominal rate for almost all scenarios, though GEE may suffer from low power.
Conclusions:
In DID estimation with a small number of groups, analysis using aggregation, permutation tests, wild cluster bootstrap, or bias-adjusted GEE is recommended.
Background:
General population survey data are presented on the lifetime prevalence of suicide attempts as well as transition probabilities to onset of ideation, plans among ideators, and attempts among ideators either with or without a plan. Risk factors for these transitions are also studied.
Methods:
Data are from part II of the National Comorbidity Survey, a nationally representative survey carried out from 1990 to 1992 in a sample of 5877 respondents aged 15 to 54 years to study prevalences and correlates of DSM-III-R disorders. Transitions are estimated using life-table analysis. Risk factors are examined using survival analysis.
Results:
Of the respondents, 13.5% reported lifetime ideation, 3.9% a plan, and 4.6% an attempt. Cumulative probabilities were 34% for the transition from ideation to a plan, 72% from a plan to an attempt, and 26% from ideation to an unplanned attempt. About 90% of unplanned and 60% of planned first attempts occurred within 1 year of the onset of ideation. All significant risk factors (female, previously married, age less than 25 years, in a recent cohort, poorly educated, and having 1 or more of the DSM-III-R disorders assessed in the survey) were more strongly related to ideation than to progression from ideation to a plan or an attempt.
Conclusions:
Prevention efforts should focus on planned attempts because of the rapid onset and unpredictability of unplanned attempts. More research is needed on the determinants of unplanned attempts.
In 2013, more than 40,000 individuals died from suicide in the United States. Restricting access to lethal means has the potential to prevent suicide, as suicidal thoughts are often transient. Permit-to-Purchase (PTP) laws for handguns could potentially reduce suicides by making it more difficult for persons at risk of suicide to purchase a handgun. We used a quasi-experimental research design with annual, state-level suicide data to evaluate changes to PTP laws in Connecticut and Missouri. Data were analyzed for 1981-2012. We used synthetic control modeling as the primary method to estimate policy effects. This methodology provided better prediction of pre-PTP-law-change trends in the two states with PTP law changes than econometric models and are thus likely to provide more accurate estimates of policy effects. The synthetic control model estimated a 15.4% reduction in firearm suicide rates associated with Connecticut's PTP law. Missouri's PTP law repeal was associated with a 16.1% increase in firearm suicide rates. Evidence that PTP laws were associated with non-firearm suicide rates was mixed in Connecticut and negative in Missouri. The findings are consistent with prior research linking firearm availability to increased risk of suicide and lower suicide risks to PTP handgun laws.
Copyright © 2015. Published by Elsevier Inc.
This analysis draws together the concept of psychache that describes the psychological pain associated with suicide and Durkheim's social integration theory in analyzing the relationship between states' spending for public welfare and their suicide rates over a 30-year period, from 1960, 1970, 1980, 1985, and 1990. Given that the threshold for enduring psychological pain varies from person to person, the questions were: Does suicide also vary with social context and has this changed over time? The answer to both questions was yes. Whereas the prevalence of divorce in combination with low population density and high rates of population change provided the context for interstate differences in suicide rates over the entire observational period and accounted for their increased variability in 1970 and 1980, this was not the case in 1985 or 1990. In both 1985 and 1990, the two variables that were important in this regard were states' spending for public welfare and race. In 1990, not only were suicide rates higher in states that spent less for public welfare than in states that spent more, but states' spending for public welfare was the only variable that accounted for the widening of differences in states' suicide rates. Given the strong prevailing skepticism that government can help solve people's problems and widespread antagonism toward government social spending, these findings carry an important message.
(C) Williams & Wilkins 1995. All Rights Reserved.
The overall importance of a risk factor for suicide in a population is determined not only by the relative risk (RR) of suicide but also the prevalence of the risk factor in the population, which can be combined with the RR to calculate the population attributable risk (PAR). This study compares risk factors from two well studied domains of suicide research - socio-economic deprivation (relatively low RR, but high population prevalence) and mental disorders (relatively high RR risk, but low population prevalence). RR and PAR associated with suicide was estimated for high prevalence ICD-10/DSM-IV psychiatric disorders and measures of socio-economic status (SES) from individual-level, population-based studies. A systematic review and meta-analysis was conducted of population-based case-control and cohort studies of suicide where relative risk estimates for males and females could be extracted. RR for any mental disorder was 7.5 (6.2-9.0) for males and 11.7 (9.7-14.1) for females, compared to RR for the lowest SES groups of 2.1 (1.5-2.8) for males and 1.5 (1.2-1.9) for females. PAR in males for low educational achievement (41%, range 19-47%) and low occupational status (33%, range 21-42%) was of a similar magnitude to affective disorders (26%, range 7-45%) and substance use disorders (9%, range 5-24%). Similarly in females the PAR for low educational achievement (20%, range 19-22%) was of a similar magnitude to affective disorders (32%, range 19-67%), substance use disorder (25%, range 5-32%) and anxiety disorder (12%, range 6-22%). The findings of the present study suggest that prevention strategies which focus on lower socio-economic strata (more distal risk factors) have the potential to have similar population-level effects as strategies which target more proximal psychiatric risk factors in the prevention and control of suicide.
In 2005, in response to the shooting death of a police officer by a paranoid man, Indiana passed a law authorizing police to seize firearms without a warrant if they believe the person owning the firearm is dangerous because the person has a mental illness and is noncompliant with psychiatric medication or if the person has a propensity for violent or unstable conduct. This study sought to determine the use of this law in Indianapolis.
All Indianapolis firearm seizure cases that had a final hearing in 2006 and 2007 were identified; demographic information, seizure circumstances, and hearing outcome were recorded.
A total of 55 cases were heard in 2006, and 78 were heard in 2007. The defendants were predominantly white (83%) and male (81%). Risk of suicide was the leading reason for confiscation (56% in 2006 and 71% in 2007), followed by substance abuse (29% and 27%, respectively), risk of violence (22% and 13%, respectively), and domestic disturbance (24% and 8%, respectively). Psychosis was a factor in only 11% and 9% of cases, respectively. A large majority of cases resulted in immediate detention (69% and 78%, respectively). In 2006, 95% of cases resulted in involuntary or voluntary surrender of the seized weapons to the court, but in 2007, only 22% of cases resulted in involuntary or voluntary surrender. However, in 2007 68% of cases resulted in court-ordered retention because of failure to appear (26%) or inability to be served (42%).
Firearm seizure by police was rarely a result of psychosis; instead, risk of suicide was the leading reason. The application of the law by both police and the court changed over the first two years of its use.
The aim of this paper was to estimate how suicide rates in the United States are affected by changes in per capita consumption during the postwar period. The analysis included Annual suicide rates and per capita alcohol consumption data (total and beverage specific) for the period 1950-2002. Gender- and age-specific models were estimated using the Box-Jenkins technique for time series analysis. No significant estimate was found for males. For females the total alcohol estimate (0.059) was significant at the 10% level whereas the spirits estimate was significant with an effect of 0.152. The results imply that a change in U.S. per capita consumption would result in a change in female suicide rates, whereas the male rates would not be affected.
It has been suggested that limiting access to firearms could prevent many suicides, but this belief is controversial. To assess the strength of the association between the availability of firearms and suicide, we studied all suicides that took place in the homes of victims in Shelby County, Tennessee, and King County, Washington, over a 32-month period.
For each suicide victim (case subject), we obtained data from police or the medical examiner and interviewed a proxy. Their answers were compared with those of control subjects from the same neighborhood, matched with the victim according to sex, race, and age range. Crude and adjusted odds ratios were calculated with matched-pairs methods.
During the study period, 803 suicides occurred in the two counties, 565 of which (70 percent) took place in the home of the victim. Fifty-eight percent (326) of these suicides were committed with a firearm. After excluding 11 case subjects for various reasons, we were able to interview 80 percent (442) of the proxies for the case subjects. Matching controls were identified for 99 percent of these subjects, producing 438 matched pairs. Univariate analyses revealed that the case subjects were more likely than the controls to have lived alone, taken prescribed psychotropic medication, been arrested, abused drugs or alcohol, or not graduated from high school. After we controlled for these characteristics through conditional logistic regression, the presence of one or more guns in the home was found to be associated with an increased risk of suicide (adjusted odds ratio, 4.8; 95 percent confidence interval, 2.7 to 8.5).
Ready availability of firearms is associated with an increased risk of suicide in the home. Owners of firearms should weigh their reasons for keeping a gun in the home against the possibility that it might someday be used in a suicide.
In the United States, more people kill themselves with firearms than with all other methods combined. A central question regarding the relation between firearms and suicide is whether the ready availability of firearms increases the suicide rate, rather than merely increasing the proportion of suicides from guns.
We used publicly available data for the nine regions and 50 states in the United States over a 10-year period (1988-1997) to examine the association between levels of household firearm ownership and rates of suicide, firearm suicide, and non-firearm suicide by age groups and gender.
In both regional and state-level analyses, for the U.S. population as a whole, for both males and females, and for virtually every age group, a robust association exists between levels of household firearm ownership and suicide rates.
Where firearm ownership levels are higher, a disproportionately large number of people die from suicide.
The social and economic characteristics of geographic areas are associated with their suicide rates. The extent to which these ecological associations are due to the characteristics of the people living in the areas (compositional effects) or the influence of the areas themselves on risk (contextual effects) is uncertain. Denmark's Medical Register on Vital Statistics and its Integrated Database for Longitudinal Labour Market Research were used to identify suicides and 20 matched controls per case in 25-60-year-old men and women between 1982 and 1997. Individual and area (municipality) measures of income, marital and employment status were obtained. There were 9011 suicides and 180,220 controls. Individual-level associations with these risk factors were little changed when controlling for contextual effects. In contrast, ecological associations of increased suicide risk with declining area levels of employment and income and increasing proportions of people living alone were much attenuated after controlling for compositional effects. We found no consistent evidence that associations with individual-level risk factors differed depending on the areas' characteristics (cross-level interactions). This analysis suggests the ecological associations to be attributed to characteristics of the residents rather than area influences on risk.
This article investigates the economic effects of conflict, using the terrorist conflict in the Basque Country as a case study. We find that, after the outbreak of terrorism in the late 1960's, per capita GDP in the Basque Country declined about 10 percentage points relative to a synthetic control region without terrorism. In addition, we use the 1998-1999 truce as a natural experiment. We find that stocks of firms with a significant part of their business in the Basque Country showed a positive relative performance when truce became credible, and a negative relative performance at the end of the cease-fire.
Circumstances and outcomes of a firearm seizure law
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