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Reducing a Suicidal Person’s Access to Lethal Means of Suicide

A Research Agenda
      Reducing the availability of highly lethal and commonly used suicide methods has been associated with declines in suicide rates of as much as 30%–50% in other countries. The theory and evidence underlying means restriction is outlined. Most evidence of its efficacy comes from population-level interventions and natural experiments. In the U.S., where 51% of suicides are completed with firearms and household firearm ownership is common and likely to remain so, reducing a suicidal person’s access to firearms will usually be accomplished not by fiat or other legislative initiative but rather by appealing to individual decision, for example, by counseling at-risk people and their families to temporarily store household firearms away from home or otherwise making household firearms inaccessible to the at-risk person until they have recovered. Providers, gatekeepers, and gun owner groups are important partners in this work. Research is needed in a number of areas: communications research to identify effective messages and messengers for “lethal means counseling,” clinical trials to identify effective interventions, translational research to ensure broad uptake of these interventions across clinical and community settings, and foundational research to better understand method choice and substitution. Approaches to suicide methods other than firearms are discussed. Means restriction is one of the few empirically based strategies to substantially reduce the number of suicide deaths.

      Introduction

      The National Action Alliance for Suicide Prevention established the Research Prioritization Task Force in 2010 to identify interventions capable of reducing the suicide rate by 20% over a 5-year period. Twelve goals emerged. We discuss the 12th: “reduce access to lethal means that people use to attempt suicide” (briefly, means restriction or means reduction).
      A suicidal person’s access to highly lethal means, or methods, of suicide can be reduced through (1) physically impeding access (e.g., using gun locks and bridge barriers); (2) reducing the lethality or toxicity of a given method (e.g., reducing carbon monoxide [CO] content of motor vehicle exhaust); or (3) reducing “cognitive access,”
      • Florentine J.B.
      • Crane C.
      Suicide prevention by limiting access to methods: a review of theory and practice.
      that is, reducing a particular method’s appeal or cognitive salience (e.g., discouraging media coverage of an emerging suicide method). We focus here largely on the first two approaches.
      Reducing access to lethal means saves lives when people who cannot readily obtain a highly lethal method either attempt with a method less likely to prove fatal or do not attempt at all (Figure 1). The rationale rests on four well-established observations. First, many suicidal crises are short-lived. A survey of people who had seriously considered suicide in the past year found that for about 30%, the suicidal period lasted under an hour.
      • Drum D.
      • Brownson C.
      • Denmark A.
      • Smith S.
      New data on the nature of suicidal crises in college students: shifting the paradigm.
      Surveys of attempters have found that the interval between deciding on suicide and actually attempting was 10 minutes or less for 24%–74% of attempters (with the lower end of the range reported by a study of those nearly dying in their attempt).
      • Williams C.L.
      • Davidson J.A.
      • Montgomery I.
      Impulsive suicidal behavior.
      • Simon O.R.
      • Swann A.C.
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      • Kresnow M.J.
      • O’Carroll P.W.
      Characteristics of impulsive suicide attempts and attempters.
      • Deisenhammer E.A.
      • Ing C.M.
      • Strauss R.
      • Kemmler G.
      • Hinterhuber H.
      • Weiss E.M.
      The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt?.
      Figure thumbnail gr1
      Figure 1Conceptual model of how reducing access to a highly lethal and commonly used suicide method saves lives at the population level.
      Note: When the restriction is effectuated by making a highly lethal method less lethal at the population level (e.g., reducing carbon monoxide content of motor vehicle exhaust), the substitution is passive. That is, people attempting suicide with the method are unaware that, in effect, a less lethal method has been substituted for a more lethal method.
      Second, the method people use in suicidal acts depends, to a non-trivial extent, on its ready availability.
      • Eddleston M.
      • Karunaratne A.
      • Weerakoon M.
      • et al.
      Choice of poison for intentional self-poisoning in rural Sri Lanka.
      • Skopek M.A.
      • Perkins R.
      Deliberate exposure to motor vehicle exhaust gas: the psychosocial profile of attempted suicide.
      Third, the proportion of attempts that result in death (case fatality ratio) varies dramatically across methods, ranging from a high of 85%–90% for firearms to a low of 1%–2% for the methods most commonly used in attempts—medication overdoses and sharp instrument wounds.
      • Spicer R.S.
      • Miller T.R.
      Suicide acts in 8 states: incidence and case fatality rates by demographics and method.
      The lethality of the method readily available during a suicidal crisis therefore plays an important role in whether the person survives an attempt; intent matters, but means also matter.
      Fourth, approximately 90% of attempters who survive a nonfatal attempt will not go on to die by suicide thereafter,
      • Owens D.
      • Horrocks J.
      • House A.
      Fatal and non-fatal repetition of self-harm. Systematic review.
      a finding that holds true even in studies focusing only on medically serious attempts, such as jumping in front of a train.
      • O’Donnell I.
      • Arthur A.J.
      • Farmer R.D.
      A follow-up study of attempted railway suicides.
      Therefore, helping people survive periods of acute suicidal risk by reducing their access to highly lethal methods is likely to help many people survive in both the short and long term.
      Reducing access to lethal means saves lives if the methods available for substitution, on balance, are less likely to prove lethal. Firearms account for more than half of suicides in the U.S. and have the highest case fatality ratio. A number of factors are theorized to influence the lethality of a given method. The first is inherent deadliness. For example, car exhaust with a high CO level will be more deadly than car exhaust with a low CO level. The second is ease of use. A method that requires technical knowledge is less accessible than one that does not.
      The third is accessibility. Given the brief duration of some suicidal crises, a lethal dose of pills in the nightstand poses a greater danger than a prescription that must be hoarded over months to accumulate a lethal dose. Similarly, a gun in the closet poses a greater risk than a very high bridge 5 miles away, even if both methods have equal lethality if used. The fourth is ability to abort mid-attempt. More people start an attempt and abort it than carry it through
      • Drum D.
      • Brownson C.
      • Denmark A.
      • Smith S.
      New data on the nature of suicidal crises in college students: shifting the paradigm.
      ; therefore, methods that can be interrupted without harm mid-attempt—such as overdose, cutting, CO poisoning, and hanging/suffocation—offer a window of opportunity for rescue or change of heart that guns and jumps do not. The fifth factor is acceptability to the attempter. Although fire, for example, is universally accessible, it is rarely used in the U.S. for suicide.
      At the population level, no measurable impact of means restriction on overall suicide rates is likely to be observed (even if, on balance, lives are saved) if the restricted method constitutes a very small proportion of all suicides or if the restricted method is of low lethality. If all sharp instruments magically disappeared, for example, in spite of their frequent use in suicide attempts there would be little measurable impact on suicide deaths, given their low case fatality ratio (sharps constitute only 2% of suicide deaths). Importantly, a possible, though unsubstantiated, unintended impact of reducing access to popular low-lethality methods may be an increase in suicide risk if attempters substitute more lethal methods.

      Research Evidence on Means Restriction

       Population-Level Natural Experiments

      Before 1960, the leading suicide method in the United Kingdom was inhalation of domestic gas. Following discovery of a cheaper, nontoxic source of natural gas in the North Sea, gas suicides fell to nearly zero. Suicides by other methods increased somewhat, but, importantly, the net result was a drop of approximately 30% in the overall suicide rate.
      • Kreitman N.
      The coal gas story. United Kingdom suicide rates, 1960–1971.
      • Gunnell D.
      • Middleton N.
      • Frankel S.
      Method availability and the prevention of suicide—a re-analysis of secular trends in England and Wales 1950–1975.
      These findings held in other countries where domestic gas was a leading method,
      • Curran P.S.
      • Lester D.
      Trends in the methods used for suicide in Northern Ireland.
      • Lester D.
      The effect of the detoxification of domestic gas in Switzerland on the suicide rate.
      but not in those where gas accounted for a small proportion of total suicides.
      • Lester D.
      The effects of detoxification of domestic gas on suicide in the U.S.
      • Lester D.
      • Abe K.
      The effect of restricting access to lethal methods for suicide: a study of suicide by domestic gas in Japan.
      • Lester D.
      Effects of detoxification of domestic gas on suicide in The Netherlands.
      Natural experiments involving decreased toxicity of motor vehicle exhaust and reduced accessibility of barbiturates, firearms, and analgesics (as well as some population-level interventions described below) also illustrate that method-specific suicide rates drop when a method becomes less available or less lethal; however, whether the overall suicide rate drops is equivocal when the method is not commonly used or is of low lethality.
      • Florentine J.B.
      • Crane C.
      Suicide prevention by limiting access to methods: a review of theory and practice.
      • Hawton K.
      Restricting access to methods of suicide.
      • Nordentoft M.
      • Qin P.
      • Helweg-Larsen K.
      • Juel K.
      Restrictions in means for suicide: an effective tool in preventing suicide: the Danish experience.
      • Daigle M.S.
      Suicide prevention through means restriction: assessing the risk of substitution. A critical review and synthesis.
      • Studdert D.M.
      • Gurrin L.C.
      • Jatkar U.
      • Pirkis J.
      Relationship between vehicle emissions laws and incidence of suicide by motor vehicle exhaust gas in Australia, 2001–2006: an ecological analysis.
      • Yip P.S.
      • Caine E.
      • Yousuf S.
      • Chang S.S.
      • Wu K.C.
      • Chen Y.Y.
      Means restriction for suicide prevention.
      • Amos T.
      • Appleby L.
      • Kiernan K.
      Changes in rates of suicide by car exhaust asphyxiation in England and Wales.
      • Reisch T.
      • Steffen T.
      • Habenstein A.
      • Tschacher W.
      Change in suicide rates in Switzerland before and after firearm restriction resulting from the 2003 “Army XXI” reform.

       Population-Level Interventions

      Pesticides are the leading suicide method in Sri Lanka. In the 1990s, the Sri Lankan government placed restrictions on sales of the most highly human-toxic agents, following which overall suicide rates dropped by 50%.
      • Gunnell D.
      • Fernando R.
      • Hewagama M.
      • Priyangika W.D.
      • Konradsen F.
      • Eddleston M.
      The impact of pesticide regulations on suicide in Sri Lanka.
      Nearly 20,000 fewer suicides occurred in the 10 years following restrictions compared with the 10 previous years. The decline in suicide was driven by a decline in poisoning suicides; non-poisoning suicides did not decline, nor did nonfatal poisonings. The underlying behavior (swallowing pesticides in a suicide attempt) did not appear to change, but thousands of lives were saved because the lethality of the behavior diminished.
      Pesticide poisoning was a highly lethal, common method of suicide prior to the policy changes. Its lethality dropped following changes; therefore, the overall suicide rate in Sri Lanka dropped driven exclusively by a drop in the pesticide suicide rate. A similarly dramatic drop in suicides was observed in Western Samoa when the pesticide paraquat became less available.
      • Bowles J.R.
      Suicide in Western Samoa: an example of a suicide prevention program in a developing country.
      Most studies in the United Kingdom on the impact that limiting access to the pain relievers co-proxamol (via market withdrawal)
      • Hawton K.
      • Bergen H.
      • Simkin S.
      • Wells C.
      • Kapur N.
      • Gunnell D.
      Six-year follow-up of impact of co-proxamol withdrawal in England and Wales on prescribing and deaths: time-series study.
      and paracetamol (via pack size limits)
      • Hawton K.
      • Bergen H.
      • Simkin S.
      • et al.
      Long term effect of reduced pack sizes of paracetamol on poisoning deaths and liver transplant activity in England and Wales: interrupted time series analyses.
      had on poisoning suicides found a significant decline in poisoning deaths by these agents without compensatory increase in other lethal poisonings. Given the small proportion of suicides overall that the two medications comprised, these studies did not look at impact on overall suicide deaths. However, Bateman’s review concluded that pack size restrictions did not reduce paracetamol deaths.
      • Bateman D.N.
      Limiting paracetamol pack size: has it worked in the UK?.
      Jumping from a very great height is a highly lethal but uncommonly employed method in the U.S. Barriers have been installed at some popular jump sites, such as tall bridges. Most
      • Pirkis J.
      • Spittal M.J.
      • Cox G.
      • Robinson J.
      • Cheung Y.T.
      • Studdert D.
      The effectiveness of structural interventions at suicide hotspots: a meta-analysis.
      • Gunnell D.
      • Miller M.
      Strategies to prevent suicide.
      (but importantly not all
      • Sinyor M.
      • Levitt A.J.
      Effect of a barrier at Bloor Street Viaduct on suicide rates in Toronto: natural experiment.
      ) studies of the impact of these barriers have found that fewer suicides occurred at the protected site without evidence of a compensatory increase in jumping suicides from other sites. Most have not assessed impact on rates overall, given the small proportion that jumps typically constitute of suicides overall.
      An intervention that found a net effect on overall suicide rates, albeit in a small population (i.e., 28 suicides annually on average pre-intervention), involved the Israeli Defense Force.
      • Lubin G.
      • Werbeloff N.
      • Halperin D.
      • Shmushkevitch M.
      • Weiser M.
      • Knobler H.Y.
      Decrease in suicide rates after a change of policy reducing access to firearms in adolescents: a naturalistic epidemiological study.
      Soldier suicides occurred disproportionately on weekends and 90% involved firearms. A 2006 policy aimed at preventing suicide required soldiers to leave their weapons on base during weekend leave. The suicide rate decreased by 40%; weekend firearm suicides dropped significantly, with no significant change in weekday suicides, and no change in non-firearm suicides.

      Firearms and Suicide in the U.S.

      In the U.S., more suicides are completed with a firearm than by all other methods combined. About one in three homes contain firearms and 51% of all suicides involve firearms.
      • Miller M.
      • Azrael D.
      • Barber C.
      Suicide mortality in the U.S.: the importance of attending to method in understanding population-level disparities in the burden of suicide.
      Miller et al.
      • Miller M.
      • Azrael D.
      • Barber C.
      Suicide mortality in the U.S.: the importance of attending to method in understanding population-level disparities in the burden of suicide.
      have provided a review of U.S. firearm suicides. All U.S. case-control studies that have examined the issue
      • Brent D.A.
      Firearms and suicide.
      • Kung H.C.
      • Pearson J.L.
      • Liu X.
      Risk factors for male and female suicide decedents ages 15–64 in the U.S. Results from the 1993 National Mortality Followback Survey.
      • Conwell Y.
      • Duberstein P.R.
      • Connor K.
      • Eberly S.
      • Cox C.
      • Caine E.D.
      Access to firearms and risk for suicide in middle-aged and older adults.
      • Kellermann A.L.
      • Rivara F.P.
      • Somes G.
      • et al.
      Suicide in the home in relation to gun ownership.
      • Brent D.A.
      • Perper J.A.
      • Allman C.J.
      • Moritz G.M.
      • Wartella M.E.
      • Zelenak J.P.
      The presence and accessibility of firearms in the homes of adolescent suicides: a case-control study.
      have found that the risk of suicide is two- to five-fold higher in gun-owning homes for all household members, with relative risk being especially high for youth and people without known psychopathology. The higher suicide risk is driven by a higher risk of firearm suicide, with no difference in non-gun suicides. Most studies, but not all, find that among gun households, suicide risk is lower when firearms are stored unloaded, locked, and separate from ammunition.
      • Grossman D.C.
      • Mueller B.A.
      • Riedy C.
      • et al.
      Gun storage practices and risk of youth suicide and unintentional firearm injuries.
      A cohort study found that handgun purchasers in California were more than twice as likely to die by suicide as were their age/sex-matched peers throughout the 6-year study period, with the increase in risk attributable to an excess risk of firearm suicide.
      • Wintemute G.J.
      • Parham C.A.
      • Beaumont J.J.
      • Wright M.
      • Drake C.
      Mortality among recent purchasers of handguns.
      Several ecologic studies in the U.S. bolster findings from the individual-level studies.
      • Miller M.
      • Lippmann S.
      • Azrael D.
      • Hemenway D.
      Household firearm ownership and rates of suicide across the 50 U.S.
      Time-series
      • Miller M.
      • Azrael D.
      • Hepburn L.
      • Hemenway D.
      • Lippmann S.J.
      The association between changes in household firearm ownership and rates of suicide in the U.S., 1981–2002.
      and cross-sectional studies that have measured firearm prevalence in relation to suicide risk have consistently found a strong association between household firearm ownership rates and rates of overall and firearm suicide (and no significant association between household firearm prevalence and non-firearm suicide).
      These findings do not appear to be accounted for by differences in underlying suicide risk among persons living in homes with guns. People living in homes with (versus without) guns, for example, are no more likely to screen positive for psychopathology or suicidal ideation, or to report having attempted suicide.
      • Sorenson S.B.
      • Vittes K.A.
      Mental health and firearms in community-based surveys: implications for suicide prevention.
      • Betz M.E.
      • Barber C.
      • Miller M.
      Suicidal behavior and firearm access: results from the second injury control and risk survey.
      • Miller M.
      • Barber C.
      • Azrael D.
      • Hemenway D.
      • Molnar B.E.
      Recent psychopathology, suicidal thoughts and suicide attempts in households with and without firearms: findings from the National Comorbidity Study Replication.
      • Ilgen M.A.
      • Zivin K.
      • McCammon R.J.
      • Valenstein M.
      Mental illness, previous suicidality, and access to guns in the U.S.
      Importantly, the heightened risk of suicide associated with the presence of a household firearm applies not only to the gun owner but to all household members.
      • Kellermann A.L.
      • Rivara F.P.
      • Somes G.
      • et al.
      Suicide in the home in relation to gun ownership.
      • Dahlberg L.L.
      • Ikeda R.M.
      • Kresnow M.J.
      Guns in the home and risk of a violent death in the home: findings from a national study.
      In aggregate, the literature on the firearm–suicide connection indicates that access to firearms does not serve as a proxy for an unmeasured third variable that drives suicide risk, but rather increases suicide risk by making it more likely that suicidal acts will involve guns and therefore, on average, prove fatal.

      Applying the Lessons of Means Restriction to the U.S.

      Suicide rates can be substantially reduced—without necessarily changing underlying mental illness or suicidal behavior—by making it more difficult to die in an act of deliberate self-harm. Despite evidence across studies (including targeted interventions, natural experiments, case control, cohort, and ecologic studies) of its potential to save lives, means restriction historically has not been prioritized in the U.S.
      One reason may be the misperception that reducing access requires embracing gun control, a politically polarizing issue. It need not. There are a variety of non-legislative approaches that respectfully engage the gun-owning community as partners in suicide prevention. Prime among them is “lethal means counseling”—advising people at risk for suicide, and their friends and family, to keep firearms away from the at-risk person until the person recovers. Below, we highlight suicide methods that may be useful targets for means restriction.
      Firearms have several characteristics that make them particularly suitable targets: They are the leading suicide method in the U.S. (approximately 19,000 deaths a year)

      CDC. Compressed Mortality File 1999-2010 on CDC WONDER Online Database. Data are compiled from Compressed Mortality File 1999-2010 Series 20 No. 2P; http://wonder.cdc.gov/cmf-icd10.html. Accessed April 2013.

      ; they are the most lethal
      • Vyrostek S.B.
      • Annest J.L.
      • Ryan G.W.
      Surveillance for fatal and nonfatal injuries–U.S., 2001.
      (substituted methods will be less likely to kill); they are both accessible and cognitively acceptable in U.S. culture; and an attempt with a gun once initiated cannot be reversed (unlike attempts with nearly every other method except jumping). If under an ideal scenario means restriction counseling reached all relevant households (households in which there is a gun and a suicidal person), and if counseling had modest results (one quarter of the households effectively kept the guns from the suicidal person), based on findings from case-control and ecologic studies, an estimated 3,600–3,900 lives would be saved in 1 year.

      Barber C, Miller M. Model for estimating reduction in U.S. suicide deaths following a reduction in suicidal adult persons’ access to firearms. In: National Action Alliance for Suicide Prevention Research Prioritization Task Force, ed. A prioritized research agenda for suicide prevention: an action plan to save lives. Rockville MD: National Institute of Mental Health and Research Prioritization Task Force, 2014.

      This approach is especially promising for youth, whose firearm suicides typically involve a family member’s gun.
      • Johnson R.M.
      • Barber C.
      • Azrael D.
      • Clark D.E.
      • Hemenway D.
      Who are the owners of firearms used in adolescent suicides?.
      Medication overdoses are by far the leading method of suicide attempt, with hundreds of thousands occurring each year.

      Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUPnet). hcupnet.ahrq.gov/.

      Although the overall case fatality ratio for medications is below 2%, some medications are markedly more lethal than others, and overdoses account for more than 5,000 deaths annually in the U.S.

      CDC. Compressed Mortality File 1999-2010 on CDC WONDER Online Database. Data are compiled from Compressed Mortality File 1999-2010 Series 20 No. 2P; http://wonder.cdc.gov/cmf-icd10.html. Accessed April 2013.

      Interventions that reduce the medication load available to at-risk persons to a level that, even when taken all at once, will not pose a severe danger, may prevent deaths and reduce the severity of attempts. Because some of the more-lethal medications also are addictive (e.g., opioids and benzodiazepines), other advantages may accrue from reducing access.
      The drop in deaths associated with motor vehicle exhaust suicides following wider use of catalytic converters suggests that more savings could be realized with further engineering changes.
      • Studdert D.M.
      • Gurrin L.C.
      • Jatkar U.
      • Pirkis J.
      Relationship between vehicle emissions laws and incidence of suicide by motor vehicle exhaust gas in Australia, 2001–2006: an ecological analysis.
      Barriers at popular jumping sites, such as the Golden Gate Bridge—particularly when no sites nearby offer comparable acceptability and lethality—will likely save lives. At 700–800 jumping suicides annually in the U.S.,

      CDC. Compressed Mortality File 1999-2010 on CDC WONDER Online Database. Data are compiled from Compressed Mortality File 1999-2010 Series 20 No. 2P; http://wonder.cdc.gov/cmf-icd10.html. Accessed April 2013.

      and about the same number from motor vehicle exhaust, these approaches may save lives but their impact on overall suicide rates may not be apparent given their small numbers.

      Barber C, Miller M. Model for estimating reduction in U.S. suicide deaths from carbon monoxide poisoning in vehicles. In: National Action Alliance for Suicide Prevention Research Prioritization Task Force, ed. A prioritized research agenda for suicide prevention: an action plan to save lives. Rockville MD: National Institute of Mental Health and Research Prioritization Task Force, 2014.

      Examples of interventions and the mechanisms by which they could save lives are illustrated in Table 1.
      Table 1Operational logic model: examples of means restriction interventions
      Outcomes (at population level)
      InputsOutputsShortMediumLong
      Train providers and gatekeepers on lethal means counseling
      • Kruesi M.J.
      • Grossman J.
      • Pennington J.M.
      • Woodward P.J.
      • Duda D.
      • Hirsch J.G.
      Suicide and violence prevention: parent education in the emergency department.
      • Johnson R.M.
      • Frank E.M.
      • Ciocca M.
      • Barber C.W.
      Training mental healthcare providers to reduce at-risk patients’ access to lethal means of suicide: evaluation of the CALM Project.
      Providers and gatekeepers counsel at-risk individuals and their families to make household guns inaccessible to at-risk personFamilies take action (e.g., store guns with a friend or at a gun club)At-risk individualsattempt with less lethal method or crisis passes before alternate attempt is madeFewer suicides overall, driven by fewer firearm suicides
      Train providers and gatekeepers on lethal means counselingPhysicians monitor prescriptions of at-risk individuals to keep total supply below toxic dose, advise families to dispose of unused medications, and substitute less toxic for more toxic medications when possibleFewer pills on hand at homeLow-planned attempts occur with fewer pillsLower severity of overdoses
      Educate insurance companies on dangers of mandatory 90-day prescription policiesAmend 90-day prescription policies to allow opt-out for at-risk patientsAt-risk patients continue receiving smaller quantities at each refillLow-planned attempts occur with fewer pillsLower severity of overdoses
      Collaborate with gun-owning groups on suicide prevention and means restrictionGun owner groups incorporate message in firearm safety training classes, brochures, and websites (sample message: Store all guns locked and unloaded; consider temporarily storing firearms offsite if a household member is at risk of suicide)Families take actionAt-risk individuals attempt with less lethal method or delay attempt; for many, crisis passesFewer suicides overall, driven by fewer firearm suicides
      Induce motor vehicle manufacturers to make engineering changesReduce toxicity of motor vehicle exhaust; install carbon monoxide–sensing gadgets that shut off idling engines when highly toxic levels accumulateAttempts with motor vehicle exhaust less likely to prove fatalFor many thwarted attempters, crisis passesFewer carbon monoxide suicides
      Induce civil engineers to make engineering changesBridge barriers erected at targeted jump sitesBarriers prevent attempts by jumpingMost methods substituted for jumping are less lethalFewer jumping suicides
      Educate hospital administrators about environmental changes to reduce inpatient suicidesHospitals install collapsible curtain and shower rails and reduce other points of ligature in psychiatric wards
      • Gunnell D.
      • Bennewith O.
      • Hawton K.
      • Simkin S.
      • Kapur N.
      The epidemiology and prevention of suicide by hanging: a systematic review.
      Changes prevent attempts by hangingMost other methods are unavailable in inpatient roomsFewer inpatient suicides overall, driven by fewer hanging suicides
      Hanging/suffocation is the second-leading mechanism of suicide death in the U.S. and its use has increased in recent years.

      CDC. Compressed Mortality File 1999-2010 on CDC WONDER Online Database. Data are compiled from Compressed Mortality File 1999-2010 Series 20 No. 2P; http://wonder.cdc.gov/cmf-icd10.html. Accessed April 2013.

      This method is not amenable to physical means restriction techniques, except in controlled settings like prisons and hospitals. Because it still ranks relatively low among ideators as a planned method,
      • Drum D.
      • Brownson C.
      • Denmark A.
      • Smith S.
      New data on the nature of suicidal crises in college students: shifting the paradigm.
      means restriction theory suggests that “cognitive access” might be reduced if efforts are made to avoid publicizing this method in traditional and social media. Similarly, care should be taken not to inadvertently increase acceptability of emerging suicide methods (such as highly lethal poisons or drug combinations) by publicizing them in traditional and social media.

      Research Needs

      The body of evidence on means reduction comes from studies examining changes in exposure to suicide methods resulting from natural experiments and interventions at the population level. Individual-level interventions are far more complex. They require identifying at-risk groups, learning the right messages to deliver, finding the right messengers to deliver them, and learning how to change behavior—not insignificant challenges. They also require changing practice among providers, healthcare/social service systems, families, and community organizations.
      A small body of literature on parents of youth with psychiatric problems suggests that families who were counseled to reduce access to firearms and medications at home were more likely to do so than those not receiving such counseling.
      • Kruesi M.J.
      • Grossman J.
      • Pennington J.M.
      • Woodward P.J.
      • Duda D.
      • Hirsch J.G.
      Suicide and violence prevention: parent education in the emergency department.
      • Brent D.A.
      • Baugher M.
      • Birmaher B.
      • Kolko D.J.
      • Bridge J.
      Compliance with recommendations to remove firearms in families participating in a clinical trial for adolescent depression.
      • McManus B.L.
      • Kruesi M.J.
      • Dontes A.E.
      • Defazio C.R.
      • Piotrowski J.T.
      • Woodward P.J.
      Child and adolescent suicide attempts: an opportunity for emergency departments to provide injury prevention education.
      This is encouraging, but more intervention research is needed in three broad categories: (1) communications research to identify and test the messages; (2) intervention evaluations to rigorously test the impact of selected interventions; and (3) translation and dissemination work to extend and adapt effective interventions to a variety of populations and settings. In addition, continued foundational research is needed to understand the dynamics governing method choice and planning and to develop a stronger surveillance infrastructure.

       Communications Research

       Communications research with at-risk individuals and their families and friends

      Communications research should examine the attitudes and knowledge that at-risk individuals and their families hold regarding means restriction and evaluate the acceptability of various strategies, particularly regarding firearms, the method for which reduced access is likely to save the greatest number of lives.
      • Walters H.
      • Kulkarni M.
      • Forman J.
      • Roeder K.
      • Travis J.
      • Valenstein M.
      Feasibility and acceptability of interventions to delay gun access in VA mental health settings.
      Examples of useful research questions to pursue via focus groups, surveys, and other methodologies include the following:
      • 1
        Which specific messages and messengers on safe firearm storage are persuasive to people at risk of suicide and their families, and does the acceptability of the messages vary by reasons for gun ownership (e.g., self-defense, hunting, sport) and by other socioeconomic factors (e.g., political views, education level)?
      • 2
        Do mistaken assumptions about suicide (e.g., once suicidal, a person remains so; most attempts are well planned long in advance; one method is about as likely to kill as another) pose a barrier to means restriction? Does education on these issues increase families’ safe storage behavior?
      • 3
        With whom, if anyone, are at-risk persons likely to feel most comfortable temporarily storing their firearms (e.g., a relative, Army buddy, storage facility, or police department)?
      • 4
        For whom is secure in-home locking (with another person holding the key) a more acceptable solution to off-site storage?
      • 5
        How should firearm safety messages be tailored when the suicidal person is a minor versus an adult, the gun owner versus non-owning member of a gun household, a crisis line caller versus inpatient, or a person at acute versus chronic risk?
      • 6
        Regarding medication safety, is the protective effect of limiting a patient with an active overdose history to shorter prescription refills (e.g., weekly rather than monthly refills) outweighed by the deleterious consequences of poorer medication compliance? Would a lockable, electronic pill-dispensing machine prove more viable?

       Communications research with providers and gatekeepers

      A number of studies have indicated that behavioral health and medical providers do not routinely conduct lethal means counseling with at-risk groups.
      • Betz M.E.
      • Miller M.
      • Barber C.
      • et al.
      Lethal means restriction for suicide prevention: beliefs and behaviors of emergency department providers.
      • Giggie M.A.
      • Olvera R.L.
      • Joshi M.N.
      Screening for risk factors associated with violence in pediatric patients presenting to a psychiatric emergency department.
      Research aimed at remedying this should (1) identify attitudinal and informational barriers that impede and facilitate routine use of lethal means counseling by providers; and (2) evaluate training programs in lethal means counseling to identify the most effective approaches.
      Messaging on firearms safety should be developed in partnership with a broad spectrum of invested parties including, importantly, gun owners, to ensure that messaging is relevant and helpful. Because many suicidal people do not explicitly seek help for their suicidal feelings, non-healthcare–related venues where suicidal people intersect with the system should be identified. The suicide risk of a person who has just been arrested on his third drunk driving charge may be as high as a patient who has been hospitalized for depression. Therefore, defense attorneys and others who see people in trouble (e.g., clergy, batterers’ counselors, social service personnel, probation/parole officers, marriage counselors, divorce attorneys) may be useful “gatekeepers” to refer people at risk and convey firearm safety messages.

       Communications research with gun owner groups

      Gun owner groups such as gun shops, shooting and hunting clubs, firearm rights groups, gun magazines, and firearm training classes offer an environment in which to deliver a basic rule of firearm safety: Be alert to signs of suicide in household members and keep guns from them until they recover.

      Vriniotis M, Barber C, Frank E, Demicco R, and the NH Firearm Safety Coalition. A suicide prevention campaign for firearm dealers in New Hampshire. Suicide and Life-Threatening Behavior 2014. In press.

      Gun owner groups typically have a strong safety culture focused on preventing the 600 unintentional firearm deaths that occur annually in the U.S.; expanding that focus to prevent the 19,000 firearm suicides is a natural next step.

      CDC. Compressed Mortality File 1999-2010 on CDC WONDER Online Database. Data are compiled from Compressed Mortality File 1999-2010 Series 20 No. 2P; http://wonder.cdc.gov/cmf-icd10.html. Accessed April 2013.

      Communications research with these groups could (1) identify facilitators and barriers to gun owner organizations embracing the role of reducing the misuse of firearms in suicide; (2) collaborate with gun owner groups to develop communications tools such as brochures, posters, training modules, and sample newsletter blurbs; and (3) test “uptake” of these communications tools (the extent to which groups use the tools when provided).
      The ultimate goal of communications research is to develop an interdisciplinary approach that will make reducing a suicidal person’s ready access to firearms as “normative” in 10 years as the “friends don’t let friends drive drunk” message

      Ad Council. Drunk Driving Prevention, 1983-Present. http://www.adcouncil.org/Our-Work/The-Classics/Drunk-Driving-Prevention. Accessed May 29, 2014.

      is today. In addition to messaging research outlined above, research is needed to clarify whether broad-scale media campaigns that raise awareness about suicide and warn families to keep guns from those at risk exert a protective, neutral, or harmful effect (the latter by normalizing suicide).
      • Niederkrotenthaler T.
      • Voracek M.
      • Herberth A.
      • et al.
      Role of media reports in completed and prevented suicide: Werther v. Papageno effects.

       Intervention Outcomes Research

       Controlled clinical trials

      As effective messages are developed, rigorous studies are needed to test the impact of lethal means counseling. Although these necessarily will be on a small scale as protocols are tested,
      • Kruesi M.J.
      • Grossman J.
      • Pennington J.M.
      • Woodward P.J.
      • Duda D.
      • Hirsch J.G.
      Suicide and violence prevention: parent education in the emergency department.
      ideally, they will be tested in populations large enough (e.g., Veterans Affairs, military, large healthcare network) to detect changes in suicide outcomes. In smaller populations, impact on individuals’ self-reported storage of guns and medications should be tested as interim outcome measures. Because these studies are conducted with suicidal individuals, researchers must attend carefully to human subjects considerations to protect study subjects.

       Other outcomes research

      At the same time, evaluations aimed at other approaches should be undertaken, including (1) technical interventions (e.g., locked electronic pill dispensers, algorithms to flag potentially dangerous prescribing in electronic medical records, personalized firearms that can only be fired by the gun owner); (2) policy interventions (e.g., amend insurance companies’ mandatory 90-day prescription policies to exempt patients at risk of overdose); and (3) outreach interventions (e.g., incorporate suicide awareness/means restriction messages in firearm safety materials).

       Translation/Dissemination Research

      The next step after effective methods of lethal means counseling (and other interventions) are identified, is institutionalizing these practices in standard clinical care among medical and behavioral health providers, and among non-traditional groups like firearm safety instructors and defense attorneys. Translation research will help identify the most effective strategies to promote implementation of effective interventions. As lethal means counseling becomes more widespread, it will be necessary to find safe storage and disposal options for firearms and toxic medications.

       Foundational Research

      In concert with developing, testing, and disseminating interventions, we must deepen our understanding of the factors that govern method choice and deliberation in suicidal behavior, and incorporate what is learned, iteratively, into ongoing interventions. Unanswered questions include the following:
      • 1
        When a suicidal person’s access to a lethal method is blocked, what determines whether he or she substitutes a more lethal versus less lethal method, or abandons an attempt entirely?
      • 2
        Under what conditions might blocking access to a low-lethality method (e.g., locking the medicine cabinet) have an unintended harmful effect of leading attempters to substitute more lethal methods?
      • 3
        What role do online and personal social networks play in method choice and technical knowledge?
      • 4
        Have method-specific case fatality ratios changed over time as the capacity for greater technical knowledge of methods increases and medical interventions change?
      • 5
        Have prescribing practices affected the severity of attempts?
      • 6
        How do gun storage practices affect suicide risk to the gun owner and household members by age and sex?
      • 7
        Among youth who die by firearm suicide, does the source of the firearm (e.g., parent’s gun, youth’s gun acquired illegally) vary across racial/ethnic/socioeconomic groups?
      Foundational research relies upon the existence of accessible, current, and valid data. The National Violent Death Reporting System provides detailed information on suicide deaths and should be expanded from its current 18 states to all 50.
      • Barber C.
      • Azrael D.
      • Hemenway D.
      A truly national National Violent Death Reporting System.
      The Behavioral Risk Factor Surveillance System has supplied valuable information on state- and national-level gun ownership rates and storage practices; however, its gun items have not been asked since 2004 and should be repeated every 2–3 years.
      • Okoro C.A.
      • Nelson D.E.
      • Mercy J.A.
      • Balluz L.S.
      • Crosby A.E.
      • Mokdad A.H.
      Prevalence of household firearms and firearm-storage practices in the 50 states and the District of Columbia: findings from the Behavioral Risk Factor Surveillance System, 2002.
      Linked hospital, pharmacy, and death certificate data will enable researchers to examine the impact of prescribing and method switching.

      Changing the Paradigm

      Currently, the suicide prevention field focuses on identifying people at risk and getting them into treatment. A challenge facing the field is to shift the paradigm such that researchers, practitioners, patients, and the broader population understand that reducing a suicidal person’s access to lethal means also has important life-saving potential. A first step is educating researchers and practitioners during training and continuing education about the evidence base.
      Reducing the availability of highly lethal and commonly used suicide methods has been associated with declines in suicide rates of as much as 30%–50% in other countries. Research on how to apply these lessons to the U.S.—including communications research to identify effective messages and messengers, clinical trials and other intervention research to identify effective interventions, and translational research to ensure broad uptake of these interventions—has the potential to substantially reduce the number of suicide deaths.

      Acknowledgments

      Publication of this article was supported by the Centers for Disease Control and Prevention, the National Institutes of Health Office of Behavioral and Social Sciences, and the National Institutes of Health Office of Disease Prevention. This support was provided as part of the National Institute of Mental Health-staffed Research Prioritization Task Force of the National Action Alliance for Suicide Prevention.
      This work was funded with support from the Joyce Foundation and Bohnett Foundation.
      No financial disclosures were reported by the authors of this paper.

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