Can We Save Lives by Limiting Access to Lethal Means for those with Mental Illnesses

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1 Can We Save Lives by Limiting Access to Lethal Means for those with Mental Illnesses Daniel W. Webster, ScD, MPH Center for Gun Policy and Research Johns Hopkins Bloomberg School of Public Health

2 Study of the serious mentally ill in CT Swanson et al., 2013 Data from CT s public mental health and criminal justice agencies during N=23,292 Diagnoses: schizophrenia, bipolar, MDD who had been hospitalized. 2 cohorts examined: 1 of 4 mental illness disqualifications for firearms No mental illness disqualifications

3 Prevalence of gun-disqualifying conditions in SMI sample. Swanson et al N % Involuntary civil commitment Incompetent to stand trial Not guilty by reason of insanity conservatorship Any mental health disqualification Criminal disqualification Any criminal or mental health disqualification Both criminal and mental health disqualification Not disqualified 14,

4 Effects of reporting mental health disqualification to NICS Swanson et al In pre-nics period, having disqualifier associated with increased risk for violence. aor = 0.69 for arrest for a violent crime for group solely impacted by NICS reporting. No change in offending in group unaffected by NICS reporting change. Offending rate lowered to level similar to those without disqualifications.

5 Evidence that firearm prohibitions for other high-risk groups reduce violence Depression, PTSD, borderline personality, substance abuse higher among IPV perps. Domestic violence restraining order prohibitions linked to intimate partner homicide reductions of 6% in state-level study (Vigdor & Mercy, 2006) and to 19% in study of large cities. (Zeoli & Webster, 2010). Violent misdemeanants gun prohibitions in CA lowered risk of violent crimes 29% among denied group (Wintemute et al., 2001)

6 Availability of Lethal Means and Suicide Risks Acknowledgement: Much of the work and data are based on the work of Matthew Miller, David Hemenway & Deb Azrael at Harvard Injury Control Research Center

7 Causal Model for Suicides mental illness or personal crisis suicidal thoughts and decision method selection injury outcome

8 What determines method selection? Determination to die? Culture? Availability of different methods?

9 The British Coal-Gas Story Most homes heated with coal in 1950s and suicide by head in oven accounted for ~ half of suicides. Execution chamber in every kitchen. British government reduced pollution in 1960s by shifting homes away from coal and toward natural gas. By early 1970s, no coal in homes and suicides dropped by one third.

10 Duke Ellington Bridge Washington, DC

11 Suicide barrier at Duke Ellington Bridge

12 Washington, DC bridge barrier Prior to mid-1980s, Duke Ellington Bridge accounted for ½ of bridge jumping suicides in the city. Similar Taft Bridge had < half as many. The difference? Ellington had waist-high barrier and Taft had chest-high barrier. Higher barrier placed on Ellington eliminated jumps while jumps from Taft went from 1.7 to 2 per year. Cut suicides by jumping in half.

13 % of suicides by method, U.S. 2010

14 % of self-harm attempts fatal by method, U.S. 2010

15 Case Fatality Rate by Method in N.E. 1 United States Miller, Azrael, & Hemenway Case Fatality Rate Gun Hanging Jump Poisoning Cut/ pierce Gas Other All Methods CFR

16 National Case-Control Study of Suicide (Wiebe 2003) 1,959 Cases from National Mortality Follow-Up Survey vs. 13,535 age-, sex-, race-matched controls from National Health Interview. OR = 3.4 for firearm ownership (OR=17 for gun suicides and OR=0.68 for non-gun suicides) Similar relationship found in other case-control studies.

17 Difference in suicide rates for 1 percentage point higher in household firearm ownership in state, Miller et al., J of Trauma, 2007 % difference in suicide rate Firearm Non-firearm Total Total pop ages ages ages ages

18 Suicide Rates United States, Suicide Rate 36 8 % Adults in Households with Guns Source: Natl. Center for Health Statistics Age-adjusted to 1940 U.S. population

19 Temporal relationship between household firearm ownership and suicide in the U.S. Miller et al., Injury Prevention, 2006 Study of change in suicides in relation to changes in gun ownership, Average per year decline: men 1.3% women 2.1% children 2.7% Controlled for changes in age, poverty, unemployment, alcohol consumption, regional fixed effects.

20 Change in suicide rate for each 10% decline in household gun ownership. Miller et al., 2006 Firearm Non-firearm Total Total pop. -4.2% -0.3% -2.5% Males -3.4% -1.1% -2.3% Females -3.4% 0.5% -1.0% Youth < age % 0.4% -4.1%

21 Youth-Focused Gun Laws Federal Laws prohibited dealer sales of handguns to < 21 yrs set 18 as min. age for handgun purchase/possession State Laws Minimum age for firearm purchase/sale and possession Child access prevention (CAP) laws. Require safe gun storage to prevent child/teen access. Age, safe storage criteria, and penalties vary.

22 Suicide rates for ages by method and year, U.S., gun nongun

23 Estimates for youth-focused firearm laws on suicide rates among ages years Webster et al., JAMA 2004 Law RR 95% CI p fed. min. sale age NS fed. min. poss. age NS state min. sale age NS state min. poss. age NS CAP permit to purchase NS

24 Model tests for ages years CAP effects didn t vary by ages covered, penalties CAP effects significant for firearm (-11%), but not for non-firearm suicides CAP laws didn t affect suicides ages years No evidence declines preceded CAP laws. Largest effect first year of CAP. CAP effects not sensitive to removal of other variables, but depend on trend model linear with break at 1995 fit best

25 Counseling parents of depressed teens to remove firearms from homes Brent et al. (2000) protocol to encourage parents of severely depressed teens to remove firearms from their homes. Usually delivered by social worker to mothers. 29 of 107 adolescents had a gun in the home. 8 of 29 (28%) reported that they followed the advise to remove guns from the home. (And a few got them!) Gun retention associated with no prior suicide attempt during most recent depressive episode, urban, anxious mother, psychopathology & substance abuse of father.

26 % change in male suicide rates associated with state gun laws by age of victim Andres & Hempstead, Permit to purchase licensing Juvenile prohibitions -14 History of mental health -3.4 Alcohol abuse -5.6 Drug abuse Misdemeanor conviction Domestic violence conviction -3.7

27 Recommendations from Consortium for Risk-Based Firearms Policy Involuntary outpatient commitment should disqualify individuals from purchasing/ possessing firearms under federal law if court finds substantial likelihood of future danger to self or others. Done! Restoration of individual s ability to purchase/ possess firearms following disqualification due to mental illness should require a qualified clinician to provide evidence on the petitioner s mental health status and affirm the petitioner is unlikely to present danger to himself or others Disqualify if 2+ DUI/DWI convictions over 5 years

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