Understanding Access to Means of Suicide Opens Door to Prevention

Suicide is most often an unpremeditated, impulsive act, so if that moment can be staved off, the individual is likely not to try suicide again, Alan Berman, Ph.D., of Washington, D.C., told attendees at a workshop on the means of violence at the Institute of Medicine last December in Washington, D.C.

“Most often, suicide is attempted by someone with immediate access to agents in the context of a temporary crisis,” said Berman, former executive director of the American Association of Suicidology. A study conducted in Houston, he said, found that 24 percent of near-lethal suicide attempts occurred within five minutes of thinking about suicide, and 70 percent happened within an hour.

“Yet 90 percent of those who survive an attempt do not go on to die by suicide,” said Berman. “We need to give them the chance for a change of mind, a change of circumstances, or some therapeutic intervention.”

Attention to and control of access to the means used for suicide offer one avenue of lessening risk for an act that takes the lives of at least 800,000 individuals worldwide each year. Globally, most people kill themselves by hanging, although firearms are the most common method in the United States. Pesticide poisoning is a very common method in China and other parts of Asia, he said.

All of these methods share common factors in the context of their cultures: they are accessible yet lethal, said Berman. People have a knowledge of and familiarity and comfort with the means.

Pesticides in China (especially in rural areas) are found commonly in the home, as are guns in America. Easy access to means is often compounded in poor or remote areas by distance from medical intervention, making rescue difficult.

Attempts to remind Chinese villagers of the dangers of pesticides or to delay access to the poisons have met with only mixed success, he said.

One antisuicide success story occurred in Great Britain. A shift from coal gas (which contains a large percentage of carbon monoxide) to natural gas cut the number of suffocation suicides from 2,500 in 1960 to just eight in 1977, contributing to an overall decline in that country’s suicide rates. Natural gas, a mixture of methane and ethane, contains far less carbon monoxide and hence is less lethal.

In the United States, efforts to restrict access to the means of suicide have met with numerous challenges. “Auto manufacturers have resisted installing engine shutoff switches to prevent carbon monoxide poisoning, and the rail industry won’t spend the money to fence off tracks, even though a majority of rail suicides occur within five miles of a station,” said Berman. Firearms restrictions are consistently resisted by the National Rifle Association, one of the most powerful lobbies in Washington, D.C.

David Hemenway, Ph.D., went on to detail research into the epidemiology of gun ownership.

“Overwhelmingly, the evidence from case control and ecological studies shows that the presence of a gun in the home increases the risk of suicide,” said Hemenway, a professor of health policy in the Harvard School of Public Health and director of the Harvard Injury Control Research Center. “Everyone in the family—not only the gun owner but the also the spouse and the children—is at increased risk.” He also cautioned against assuming that mental illness, rather than easy access to firearms, is at fault when a person uses a gun to take his or her own life.

A gun in the home increases the risk of death for women, who are less likely to own guns but more likely to be a victim of domestic violence. It also increases the risk of child suicide by a factor of 10 and of unintentional injury by a factor of nine. Gun owning also raises the risk of suicide for adult men.

Stronger gun laws appear to reduce risk of homicide and suicide, but those effects cannot be attributed to any specific law, complicating policy planning, said Hemenway. Updated and better-quality research with greater statistical power is needed to clarify associations between gun laws and risks for firearms suicide, homicide, and injury. ■