In 2015, the National Center for Health Statistics found that in the U.S. alone, 9.8 million adults endorsed having serious suicidal thoughts, and 1.3 million adults reported a suicide attempt during the past year (World Health Organization). Suicide experts advocate for restricting access to lethal means as an effective strategy to reduce suicide rates. In this blog, I plan to review the efficacy of reducing access to various lethal means.
One of the earliest illustrations of the efficacy of limiting access to lethal means was in the United Kingdom when domestic gas was replaced with a non-toxic alternative in the 1960s, resulting in a 30 percent reduction in the national suicide rate. In a systematic review of the literature, Mann and colleagues revealed similar outcomes in Switzerland, Australia, Japan and the U.S. as a result of gas detoxification. Interestingly, results showed a decline in suicide rates not only related to gas toxicity, but a decline in the overall suicide rates in those countries (Mann et al., 2005).
While rare in North America, pesticides, and other agricultural chemicals are a common method of suicide in developing countries accounting for more than one-third of suicides globally (World Health Organization, 2009). In China, provinces where pesticides are commonly stored in homes have significantly higher rates of suicide than provinces where pesticides are not. With increased urbanization, access to pesticides has diminished and suicide rates have dropped (National Academies of Sciences, Engineering, and Medicine, 2018). To combat suicide in rural provinces, an educational campaign was rolled out promoting the installation of lockboxes. The lockboxes had two keys, necessitating two people (often husband and wife) being required to open the box. Provinces in which lockboxes were promoted showed a 23 percent decrease in suicide rates compared to a two percent increase in those provinces in which no such campaign was promoted (National Academies of Sciences, Engineering, and Medicine, 2018).
Sri Lanka saw an eightfold increase in suicide rates from 1950 to 1995, mostly attributed to the increased access to toxic pesticides, a consequence of the agricultural revolution. In response, the Sri Lankan government placed restrictions on the sale of toxic pesticides and banned several of the most highly toxic pesticides. By 2005, the overall suicide rate in Sri Lanka dropped by 50 percent (Gunnell et al., 2007; Knipe et al., 2017; Miller et al., 2012; Jager-Hyman et al., 2017).
A number of large epidemiological studies have examined the overall population suicide rates associated with restricting access to lethal prescription medications and replacing them with safer, less toxic medication options. In Australia, barbiturate prescriptions were substituted with less lethal medications such as benzodiazepines and antidepressant drugs, resulting in a steady decline in suicide rates in the years following this change. Marked decreases in the rates of barbiturate related deaths were also observed with limitations placed on these prescriptions in Britain, Norway, and Sweden.
Countering the significant rates of suicide deaths occurring as a result of tricyclic antidepressant drug overdoses, the United Kingdom put forth concerted efforts to diminish utilization of these prescriptions. Tricyclics and neuroleptics, which accounted for 15 percent of suicide deaths in 1987, were replaced with Selective Serotonin Reuptake Inhibitors (SSRIs). Studies demonstrated a significant decline in suicide rates after the introduction of SSRIs (Hawton et al., 2010; Kapur et al.,1992; Qin et al., 2014).
In response to an increasing number of self-poisonings with analgesics (acetaminophens and salicylates) in the United Kingdom, researchers examined the impact of limiting access to the pain relievers co-proxamol and paracetamol had on poisoning suicides (Hawton, 2002; Hawton et al., 2012). In 1998, Parliament passed legislation limiting pharmacies to 32 tablets per sale and non-pharmacy outlets were limited to 16 tablets per sale. In addition to these restrictions, printed warnings on the dangers of overdose were included on all medication packages. Suicide deaths by these toxic medications decreased during the six years following these legislative changes, with a 22 percent decrease in suicide rates in the first year alone. No compensatory increases in other lethal poisonings were observed. In fact, Hawton and colleagues (2013) were able to determine the long-term effect of this legislative change, revealing a 43 percent reduction in estimated suicide deaths resulting from paracetamol over the 11¼ years after the legislation. The researchers indicated this was equivalent to an estimated 765 fewer deaths over this period.
KNIVES AND SHARP OBJECTS:
Knives and other sharp objects are common household and workplace tools, thus extensively available. On account of the utility of knives and other sharp objects, research on methods to limit access to these is not as well developed as it is for firearms. Legislation aimed at reducing access to knives and other sharp objects is often akin to that of firearms.
The United Kingdom’s Violent Crime Reduction Act of 2006 created legislative measures deeming it a criminal offense to carry a knife or other sharp object in public. In addition, certain types of knives (e.g., flick knives) have been banned completely, the age restriction for purchasing knives has increased and the maximum prison sentence for possession has been extended. To enforce legislation, a "stop and search" policy was implemented, authorizing police to search individuals suspected of carrying knives. In Scotland, a licensing system was developed for a business that sells knives. The impact of these legislative changes on access to sharp objects is difficult to systematically study given the low base rate of suicide deaths occurring as a result of self-inflicted lacerations. As a result, the effects of these legislative changes have not been well measured.
In 2009, the World Health Organization (WHO) examined the effects of firearm legislation changes. In response to a mass shooting, the Australian government prohibited semi-automatic and pump-action shotguns and rifles leading to reduced rates of violent firearm deaths. In Austria, the government enacted an age restriction for the purchase of firearms, background checks, a three-day waiting period between receiving a firearm license and purchasing the firearm, psychological testing, and passing a written test. Following these legislative changes, Austrian suicide and homicide rates began to decrease. Following Australia and Austria, Brazil sanctioned age restriction and background checks for the purchase of firearms. In addition, the government prohibited unregistered firearms and banned permits to carry firearms outside one's home or work. During this same time, voluntary disarmament was established leading to the collection of 450,000 firearms. In only two years, Brazil's firearm deaths significantly declined. New Zealand also found significant reductions in firearm-related suicides resulting from legislation necessitating individuals be photographed and assessed by police, pass a written exam, and establish safe storage of both firearms and ammunition (in separate storage areas) to qualify for a firearm license. In Colombia, local legislation prohibited carrying firearms in public in the cities of Cali and Bogotá on holidays, weekends following paydays, and election days. Bans were enforced with patrolled checkpoints and police searches. Rates of violent deaths were lower on days when the ban was in place, compared to similar days the ban was not in place. Another example is the 2006 Israeli Defense Force (IDF) policy requiring all military firearms be left on base when IDF soldiers go home over the weekend or on off-duty periods. There was a 40% decline in the number of soldier suicides annually after the change of policy reducing access to firearms.
An analysis of 36 wealthy nations revealed that the U.S. had the highest overall firearm mortality rate and the highest prevalence of firearm suicides, making firearm violence an important public health concern. In the U.S., firearms account for almost half of our nation’s suicides. The annual rate of firearm suicides is double the annual rate of firearm homicides (Fowler, Dahlberg, Haileyesus, & Annest, 2015). About one in three homes contain firearms. There is strong evidence that access to firearms, whether from household availability or a new purchase, is associated with a two- to five-fold increased risk of suicide (Barber & Miller, 2014). Furthermore, among households with firearms, suicide risk is lower when firearms are stored unloaded, locked, and separately from ammunition (Barber & Miller, 2014; Miller et al., 2012).
There are at least 875 million firearms across the globe, 75 percent of which are owned by civilians. The WHO (2009) identified that one-third of the world's firearm owners reside in the U.S. concluding that America has developed a powerful relationship with firearm ownership, which may stem from a culture that values autonomy. However, firearm ownership has been correlated with increased suicide risk. In response to the increased suicide prevalence, many U.S. states have sanctioned state-specific laws that restrict access to firearms. Generally, research shows that states with laws requiring waiting periods, background checks, gunlocks, required permits, registration procedures, or license regulations have lower suicide rates than states that do not have such policies (Ludwing & Cook, 2000).
An early example of firearms restriction in the U.S. is the District of Columbia’s Firearms Control Regulations Act that passed September 24, 1976, banning the purchase, sale, transfer, or possession of handguns by civilians (Loftin et al., 1991). More specifically the law required that: 1) all firearms be registered; 2) firearm owners at the time of legislation register firearms within 60 days or they would be deemed illegal 3) restrictions were determined based on age, criminal record, physical fitness, and knowledge of firearms laws and safe usage 4) newly acquired firearms must be obtained from licensed dealer; and 5) firearm owners must keep their firearms unloaded and disassembled or locked up whenever not in use. Penalties included fines and incarceration (Loftin et al., 1991). Restrictive licensing of firearms was associated with a prompt decline of firearms deaths (both suicide and homicide), showing a 23% reduction in firearm suicides rates. In comparison, adjacent metropolitan areas in Maryland and Virginia, which were not subject to the changes in firearm regulations, did not show comparable reductions in firearm-related deaths, highlighting the direct impact of legislation on the reduced firearm deaths. Interestingly, there were no corresponding reductions in the violent death rates by other means. There were also no increases in other methods of violent deaths, contradicting the notion of means substitution. Years later the law was overturned, leading to increased firearm suicide rates in D.C. (Loftin et al., 1991).
Addressing the need for restriction of lethal means, the 2012 National Strategy for Suicide Prevention called for “efforts to reduce access to lethal means of suicide among individuals with identified suicide risk” (Office of the U.S. Surgeon General 2012, p. 43). One significant obstacle has been the substitution hypothesis positing that if one suicide method is unavailable, it will be replaced with another. Nevertheless, decades of population-based data have disconfirmed this notion. Moreover, if access to the most highly lethal means is reduced, even in cases where substitution occurs, the proportion of individuals who survive suicide attempts is certain to increase. Firearms represent the highest case fatality ratio (proportion of suicide attempts that result in death), ranging from 85-90 percent. In addition, firearms are the most common method for suicide in Service members and Veterans (Barber & Miller, 2014), restricting access to lethal means is vital to suicide prevention efforts. One effective technique is means safety counseling, a collaborative clinical intervention involving the patient’s support systems in determining a plan for modification of the immediate environment to decrease access to lethal means with the aim of increasing safety (Bryan, Stone & Rudd, 2011). Means safety counseling has been shown to have significant empirical support and is frequently cited as a vital risk management strategy (American Psychiatric Association, 2003).
For more information on Means Safety Counseling, we invite you to attend our upcoming CDP Presents webinar with Megan McCarthy Lethal Means Safety Counseling to Reduce Suicide Risk on September 27th, 2018
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Sharon Birman, Psy.D., is a Military Behavioral Health Psychologist working with the Military Training Programs at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
Barber, C. W., & Miller, M. J. (2014). Reducing a suicidal person's access to lethal means of suicide. American Journal of Preventive Medicine, 47(3), S264-S272. doi:10.1016/j.amepre.2014.05.028
Bryan, C. J., Stone, S. L., & Rudd, D. M. (2011). A practical, evidence-based approach for means-restriction counseling with suicidal patients. Professional Psychology, Research and Practice, 42(5), 339-346. doi:10.1037/a0025051
Fowler, K. A., Dahlberg, L. L., Haileyesus, T., & Annest, J. L. (2015). Firearm injuries in the United States. Preventive Medicine, 79, 5-14. doi:10.1016/j.ypmed.2015.06.002
Gunnell, D., Fernando, R., Hewagama, M., Priyangika, W. D. D., Konradsen, F., & Eddleston, M. (2007). The impact of pesticide regulations on suicide in Sri Lanka. International Journal of Epidemiology, 36(6), 1235-1242. doi:10.1093/ije/dym164
Hawton, K. (2002). United Kingdom legislation on pack sizes of analgesics: Background,
rationale, and effects on suicide and deliberate self-harm. Suicide and Life-Threatening Behavior, 32(3), 223-229. doi:10.1521/suli.22.214.171.12469
Hawton, K., Bergen, H., Simkin, S., Cooper, J., Waters, K., Gunnell, D., & Kapur, N. (2010). Toxicity of antidepressants: Rates of suicide relative to prescribing and non-fatal overdose. British Journal of Psychiatry, 196(5), 354-358. doi:10.1192/bjp.bp.109.070219
Hawton, K., Bergen, H., Simkin, S., Dodd, S., Pocock, P., Bernal, W., . . . Kapur, N. (2013). Long term effect of reduced pack sizes of paracetamol on poisoning deaths and liver transplant activity in England and Wales: Interrupted time series analyses. British Medical Journal, 346(7895), 15-24 doi:10.1136/bmj.f403
Hawton, K., Bergen, H., Simkin, S., Wells, C., Kapur, N., & Gunnell, D. (2012). Six-year follow-up of impact of co-proxamol withdrawal in England and Wales on prescribing and deaths: Time-series study. PLoS Medicine, 9(5), e1001213. doi:10.1371/journal.pmed.1001213
Jager-Hyman, S., Marcus, S. C., Ahmedani, B. K., Zeber, J. E., Fein, J. A., Brown, G. K., . . . Beidas, R. S. (2017). Developing implementation strategies for firearm safety promotion in pediatric primary care for suicide prevention in two large US health systems: A study protocol for a mixed-methods implementation study. BMJ Open, 7(6), e014407. doi:10.1136/bmjopen-2016-014407
Kapur, S., Mieczkowski, T., & Mann, J. J. (1992). Antidepressant medications and the relative risk of suicide attempt and suicide. JAMA, 268(24), 3441-3445. doi:10.1001/jama.1992.03490240049035
Knipe, D. W., Chang, S., Dawson, A., Eddleston, M., Konradsen, F., Metcalfe, C., & Gunnell, D. (2017). Suicide prevention through means restriction: Impact of the 2008-2011 pesticide restrictions on suicide in Sri Lanka. Plos One, 12(4), e0172893. doi:10.1371/journal.pone.0172893
Loftin, C., McDowall, D., Wiersema, B., & Cottey, T. J. (1991). Effects of restrictive licensing of handguns on homicide and suicide in the District of Columbia. The New England Journal of Medicine, 325(23), 1615-1620. doi:10.1056/NEJM199112053252305
Ludwig, J., & Cook, P. J. (2000). Homicide and suicide rates associated with implementation of the Brady Handgun Violence Prevention Act. JAMA, 284(5), 585-591. doi:10.1001/jama.284.5.585
Mann, J. J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., Haas, A., . . . Hendin, H. (2005). Suicide prevention strategies: A systematic review. JAMA, 294(16), 2064-2074. doi:10.1001/jama.294.16.2064
Miller, M., Azrael, D., & Barber, C. (2012). Suicide mortality in the United States: The importance of attending to method in understanding population-level disparities in the burden of suicide. Annual Review of Public Health, 33(1), 393-408. doi:10.1146/annurev-publhealth-031811-124636
Office of the U.S. Surgeon General (2012). 2012 national strategy for suicide prevention: Goals and objectives for action: A report of the U.S. surgeon general and of the national action alliance for suicide prevention. Retrieved from https://www.surgeongeneral.gov/library/reports/national- ... strategy-suicide-prevention/full-report.pdf
Swanson, J. W., McGinty, E., Fazel, S., & Mays, V.M. (2015). Mental illness and reduction of gun violence and suicide: Bringing epidemiologic research to policy. Annals of Epidemiology, 25(5), 366-376. doi:10.1016/j.annepidem.2014.03.004
Qin, B., Zhang, Y., Zhou, X., Cheng, P., Liu, Y., Chen, J., . . . Xie, P. (2014). Selective serotonin reuptake inhibitors versus tricyclic antidepressants in young patients: A meta-analysis of efficacy and acceptability. Clinical Therapeutics, 36(7), 1087-1095. doi:10.1016/j.clinthera.2014.06.001
Vizzard, W. J. (2015). The current and future state of gun policy in the United States. .Journal of Criminal Law and Criminology, 104(4), 879-904.
World Health Organization. (2009). Guns, knives and pesticides: Reducing access to lethal means. Geneva, Switzerland: World Health Organization Press.