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August 24, 2017

Why do more rural residents die by suicide? The answer could be access to guns, study says

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    Firearm access could account for the disparity in suicide mortality rates between rural and urban areas, according to a new study in the American Journal of Public Health—and some gun shop owners are taking steps to help reduce those rates.

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    Study details

    For the study, researchers from the Johns Hopkins Bloomberg School of Public Health used state medical examiner's data to assess a sample of 6,196 deaths by suicide among Maryland residents over the age of 15.

    The researchers found that, between 2003 and 2015, rural regions had 24 deaths by suicide for every 100,000 people, compared with 16 deaths by suicide for every 100,000 people in urban counties. And CDC data show similar trends nationwide, with 19 per 100,000 people dying by suicide in rural regions, compared with 11 per 100,000 people in urban areas.

    According to the researchers, about half of all suicide-related deaths in the state involved a firearm—but that figure was 66 percent higher in rural areas than urban areas. When the researchers excluded suicide-related deaths involving firearms from the data set they found no meaningful difference in the rate of death by suicide between rural and urban areas.

    The researchers also looked at the data by gender and found no difference in suicide-related deaths involving firearms between rural and urban areas among women—though the overall suicide rate among women was 37 percent higher in urban areas. According to the researchers, men accounted for the majority of suicide-related deaths involving firearms—89 percent—and also made up the higher rural firearm suicide-related death rate.


    CDC data show suicide rates are higher in rural areas than in urban centers.

    The researchers said more research is needed to determine why the overall rate of death by suicide is so much higher in rural areas than in urban areas, but they hypothesized it could be linked to increased rates of economic isolation, greater economic disparities, difficulty accessing medical care—and, likely, increased access to firearms.

    Paul Nestadt, the study's lead author and a postdoctoral fellow in Johns Hopkins Bloomberg School of Public Health's psychiatric epidemiology training program, said, "In rural areas, we need to be aware of the outsize role that gun safety and availability play," adding, "If we fail to recognize the role of guns in suicides, we are missing an opportunity to prevent death."

    Nestadt continued, "Most of the other leading causes of death are going down. Suicides are going up—and firearms are a big reason why," adding, "If there is no gun around, many people won't have the means to follow through on those impulses, or would use a less lethal method with a much greater chance of survival."

    But other experts have noted the difficulty addressing this issue, KHN reports. Jameson Hirsch, an associate professor of clinical psychology at East Tennessee State University, said, "We're up against something really difficult in the United States, because the key to success is proper storage, or removal of firearms from homes where somebody has a mental illness or is imminently suicidal," adding, "[But] it's such a tough sell. … You want to respect people's rights."

    How gun shop owners are trying to help

    To help prevent firearm-related deaths by suicide, some gun shop owners are educating themselves about certain "tells" an individual might display indicating he or she is thinking about purchasing a gun to attempt death by suicide—and then working to dissuade those consumers from following through their plans, KHN reports.

    For instance, John Yule, a gun shop owner in New Hampshire, said he has had conversations with people whom he believes may be at risk. "We're not trying to step on anyone's toes or deny them any rights," Yule said. "[But] you can guide them, or suggest to them or talk them into a different approach."

    Like many other gun shop owners, KHN reports, Yule also stocks his store with suicide prevention cards and pamphlets recommending that if gunowners believe someone in their house might be at risk of death by suicide, they store their firearms offsite.

    According to KHN, the methods seem minute, but research suggests that delaying someone who is contemplating death by suicide from accessing a firearm—even if only making them go home and return later—"can make all the difference." The impulse might pass, or the individual might try a method of suicide with lower success rates, such as an overdose, KHN reports.

    That said, Elaine Frank, co-chair of New Hampshire's Firearms Safety Coalition, said it will take several years to collect qualitative data on whether efforts by gun shop owners are helpful—and even if they are, they are still only reaching the "low-hanging fruit." Research, while limited, suggests that people who use a firearm during a death by suicide have typically owned the weapon for at least a week, she said, which suggests that more education is needed to inform people to recognize signs of mental illness, and, if necessary, temporarily remove firearms when appropriate.

    Nestadt agreed, noting that further efforts are required to address the suicide rate, such as improved access to mental health care, restricting access to other forms of self-harm, the destigmatization of depression, and facilitating discussions about suicide prevention between physicians and patients. "We're talking about everything you can do on every side. No one thing is going to fix everything," Nestadt said. "Anything we can do to chip away at this national problem, the better" (Luthra, Kaiser Health News, 8/18; Mozes, HealthDay News/U.S. News & World Report, 8/18; Bakalar, "Well," New York Times, 8/17).

    Learn 3 trends increasing behavioral health utilization

    Outpatient behavioral health care includes behavioral health services delivered by any care team member in any setting outside of the inpatient hospital—from services delivered by behavioral health professionals to care delivered by primary care physicians, care managers, and social workers.

    Learn how changes in demographics, reimbursement, and the outmigration of services are increasing behavioral health utilization in the outpatient setting.

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