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© 2006 American Public Health Association
DOI: 10.2105/AJPH.2006.088641
LETTER |
Kerry L. Knox is with the Department of Community and Preventive Medicine and Eric D. Caine is with the Department of Psychiatry, University of Rochester, Rochester, NY.
Correspondence: Requests for reprints should be sent to Kerry L. Knox, PhD, Department of Community and Preventive Medicine, University of Rochester, 601 Elmwood Ave, Box 644, Rochester, NY 14642 (e-mail: kerry_knox{at}urmc.rochester.edu).
We agree with Sorenson and Miller that firearms control in the United States has significant potential public health implications—for self-inflicted injury and suicide, homicide, and accidental injury. We also recognize the substantial social, cultural, and political implications of any public health–oriented discussion about firearms, a discussion that is likely to continue for many years into the future.1
While there is some indication that restriction of firearms in the homes of adolescents with previous histories of self-harm may be effective in reducing the risk of suicide,2 the focus of our article was to move priority-setting discussions beyond consideration of death rates (which are highest among older White men) and beyond common areas of public attention (most often involving school-aged children) to a broader view of the burdens of death and loss associated with suicide. Middle-aged men have not been the focus of suicide prevention efforts in the United States, despite the disproportionately high public health burden caused by suicide in this group. Feasible and effective approaches to suicide prevention such as those implemented and sustained through the US Air Force’s Suicide Prevention Program3 demonstrate the greatest promise for reducing the years of potential life lost and associated economic losses owing to suicide among men in the middle years of life.
Whether or not control of firearms or other means serves as an effective suicide prevention method remains an empirical question that requires careful examination. Rich et al.4 found that in San Diego, Calif, and Toronto, Ontario, gun control legislation resulted in a decrease in suicide by firearms among males. In both locations, there was a concomitant increase in the number of males who leaped to their deaths, so that the overall suicide rate for males did not change during the years after gun control legislation. In the United Kingdom, a change from coal-derived cooking gas containing carbon monoxide to gas from the North Sea was associated with an immediate decline in deaths from suicide. This reduction eventually faded as other means were used.5 Changes in the packaging of paracetamol (acetaminophen) and aspirin have been associated with fewer related deaths and liver transplants; it remains unclear whether there has been a decrease in overall deaths or deaths from poisoning.6
At the same time, the work of our colleagues and other researchers7,8 and ample clinical experience underscores the fact that family members and physicians too often have failed to ask potentially suicidal individuals whether or not they own or have access to guns. The education of physicians and health care workers is minimal in this respect. We surely would recommend the development of coalitions to enhance such training—coalitions including medical educators and gun safety–promoting organizations such as the National Rifle Association, whose courses for youths have taught the careful use of guns for many generations.
References
1. Knox KL. Interventions for suicide. In: Doll, L, Mercy, J, Bonzo, S, Sleet, DA, eds. Handbook on Injury and Violence Prevention Interventions. Secaucus, NJ: Springer. In press.
2. Kruesi MJ, Grossman J, Pennington JM, Woodward P, Duda D, Hirsch JG. Suicide and violence prevention: parent education in the emergency department. J Am Acad Child Adolesc Psychiatry. 1999;38:250–255.[CrossRef][Web of Science][Medline]
3. Knox KL, Litts DA, Talcott GW, Feig JC, Caine ED. Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the United States Air Force: cohort study. BMJ. 2003;327: 1376–1380.
4. Rich CL, Young JG, Fowler RC, Wagner J, Black NA. Guns and suicide: possible effects of some specific legislation. Am J Psychiatry. 1990; 147(3):342–346.
5. Kreitman N. The coal gas story. United Kingdom suicide rates, 1960–71. Br J Prev Soc Med. 1976;30:86–93.[Web of Science][Medline]
6. Hawton K, Townsend E, Deeks J, et al. Effects of legislation restricting pack sizes of paracetamol and salicylate on self poisoning in the United Kingdom: before and after study. BMJ. 2001;322:1203–1207.
7. Conwell Y, Duberstein PR, Connor K, Eberly S, Cox C, Caine ED. Access to firearms and risk for suicide in middle-aged and older adults. Am J Geriatr Psychiatry. 2002;10(4):407–416.[CrossRef][Web of Science][Medline]
8. Oslin DW, Zubritsky C, Brown G, Mullahy M, Puliafico A, Ten Have T. Managing suicide risk in late life: access to firearms as a public health risk. Am J Geriatr Psychiatry. 2004;12(1):30–36.[CrossRef][Web of Science][Medline]
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