Decrease in suicide rates after a change of policy reducing access to firearms in adolescents: a naturalistic epidemiological study.
ABSTRACT The use of firearms is a common means of suicide. We examined the effect of a policy change in the Israeli Defense Forces reducing adolescents' access to firearms on rates of suicide. Following the policy change, suicide rates decreased significantly by 40%. Most of this decrease was due to decrease in suicide using firearms over the weekend. There were no significant changes in rates of suicide during weekdays. Decreasing access to firearms significantly decreases rates of suicide among adolescents. The results of this study illustrate the ability of a relatively simple change in policy to have a major impact on suicide rates.
- [Show abstract] [Hide abstract]
ABSTRACT: Background: Suicide is the leading cause of soldier death in the Israeli Defense Forces (IDF) in peace time. Suicide attempt (SA) and non-suicidal self-injury (NSSI) are risk factors for death by suicide in civilian studies and therefore their predictive value needs to be determined in the military. Methods: All army screening, psychometric and demographic data on consecutive cases of IDF soldier self-harm during the years 2010-2011were analyzed. The Columbia Suicide Severity Rating Scale was used retrospectively to classify self-harm as suicidal or NSSI. The Suicide Ideation Scale and the Suicide Intent Scale were scored retrospectively by trained clinical psychologists.Results: A 107 soldiers reported self-harm during the study period, comprising 70 SA and 37 with NSSI. The most prevalent diagnosis was personality disorder (n = 48). Soldiers with any mood/anxiety disorders comprised the smallest group (n = 21) and included major depression, dysthymia, anxiety and posttraumatic stress disorder. Soldiers with NSSI (n = 37) did not differ in any of the characteristics from those who attempted suicide (n = 70). Unlike the well-known female dominance in both SA and NSSI patients in other settings, males dominated this army sample in both groups.Conclusion: Soldiers with self-harm (both SA and NSSI) cannot be easily distinguished by any demographics or specific psychological attributes detectable at induction, and the scales used in suicide research cannot predict an attempt or NSSI. Unlike civilian samples, males dominated attempter and NSSI groups and the reason for this may be multifactorial. These retrospective findings, if replicated, indicate the need for different screening strategies at induction into the military.Archives of suicide research: official journal of the International Academy for Suicide Research 10/2014;
- [Show abstract] [Hide abstract]
ABSTRACT: 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.American Journal of Preventive Medicine 09/2014; 47(3):S264–S272. · 4.28 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Suicides by carbon monoxide poisoning resulting from burning barbecue charcoal reached epidemic levels in Hong Kong and Taiwan within 5 y of the first reported cases in the early 2000s. The objectives of this analysis were to investigate (i) time trends and regional patterns of charcoal-burning suicide throughout East/Southeast Asia during the time period 1995-2011 and (ii) whether any rises in use of this method were associated with increases in overall suicide rates. Sex- and age-specific trends over time were also examined to identify the demographic groups showing the greatest increases in charcoal-burning suicide rates across different countries. We used data on suicides by gases other than domestic gas for Hong Kong, Japan, the Republic of Korea, Taiwan, and Singapore in the years 1995/1996-2011. Similar data for Malaysia, the Philippines, and Thailand were also extracted but were incomplete. Graphical and joinpoint regression analyses were used to examine time trends in suicide, and negative binomial regression analysis to study sex- and age-specific patterns. In 1995/1996, charcoal-burning suicides accounted for <1% of all suicides in all study countries, except in Japan (5%), but they increased to account for 13%, 24%, 10%, 7%, and 5% of all suicides in Hong Kong, Taiwan, Japan, the Republic of Korea, and Singapore, respectively, in 2011. Rises were first seen in Hong Kong after 1998 (95% CI 1997-1999), followed by Singapore in 1999 (95% CI 1998-2001), Taiwan in 2000 (95% CI 1999-2001), Japan in 2002 (95% CI 1999-2003), and the Republic of Korea in 2007 (95% CI 2006-2008). No marked increases were seen in Malaysia, the Philippines, or Thailand. There was some evidence that charcoal-burning suicides were associated with an increase in overall suicide rates in Hong Kong, Taiwan, and Japan (for females), but not in Japan (for males), the Republic of Korea, and Singapore. Rates of change in charcoal-burning suicide rate did not differ by sex/age group in Taiwan and Hong Kong but appeared to be greatest in people aged 15-24 y in Japan and people aged 25-64 y in the Republic of Korea. The lack of specific codes for charcoal-burning suicide in the International Classification of Diseases and variations in coding practice in different countries are potential limitations of this study. Charcoal-burning suicides increased markedly in some East/Southeast Asian countries (Hong Kong, Taiwan, Japan, the Republic of Korea, and Singapore) in the first decade of the 21st century, but such rises were not experienced by all countries in the region. In countries with a rise in charcoal-burning suicide rates, the timing, scale, and sex/age pattern of increases varied by country. Factors underlying these variations require further investigation, but may include differences in culture or in media portrayals of the method. Please see later in the article for the Editors' Summary.PLoS Medicine 04/2014; 11(4):e1001622. · 14.00 Impact Factor
421Suicide and Life-Threatening Behavior 40(5) November 2010
2010 The American Association of Suicidology
Decrease in Suicide Rates After
a Change of Policy Reducing
Access to Firearms in Adolescents:
A Naturalistic Epidemiological Study
Gad Lubin, MD, Nomi Werbeloff, PhD, Demian Halperin, MD,
Mordechai Shmushkevitch, MD, Mark Weiser, MD, and Haim Y. Knobler, MD
The use of firearms is a common means of suicide. We examined the effect
of a policy change in the Israeli Defense Forces reducing adolescents’ access to
firearms on rates of suicide. Following the policy change, suicide rates decreased
significantly by 40%. Most of this decrease was due to decrease in suicide using
firearms over the weekend. There were no significant changes in rates of suicide
during weekdays. Decreasing access to firearms significantly decreases rates of
suicide among adolescents. The results of this study illustrate the ability of a rela-
tively simple change in policy to have a major impact on suicide rates.
Suicide is the third most common cause of
death among children and adolescents aged
10 to 24 years in the United States. Around
the world, use of firearms is a common means
of suicide, ranging from 38% of all suicides
in Europe (Perret, Abudureheman, Perret-
Catipovic, Flomenbaum, & La Harpe, 2006)
to 60–70% in the United States (Shields,
Hunsaker, & Hunsaker, 2006; Singh & La-
throp, 2008). In particular, the availability of
firearms has been shown to have an effect on
suicide rates among adolescents and young
men (Brent et al., 1991; Brent et al., 1993;
Grossman et al., 2005; Kellermann et al.,
1992; Miller, Azrael, & Hemenway, 2002;
Miller, Hemenway, & Azrael, 2004; Miller,
Lippmann, Azrael, & Hemenway, 2007; Shen-
assa, Rogers, Spaulding, & Roberts, 2004;
Sloan, Rivara, Reay, Ferris, & Kellermann,
1990). Further, more stringent regulation of
access to firearms has been shown to reduce
overall suicide rates (Kellermann et al., 1992;
Lewis, Hawton, & Jones, 1997; Marzuk et
al., 1992) and rates of suicide by firearms
(Caron, 2004; Carrington & Moyer, 1994;
Goldney, 2006; Haw et al., 2004; Kapusta,
Etzersdorfer, Krall, & Sonneck, 2007; Loftin,
McDowall, Wiersma, & Cottey, 1991; Lud-
wig & Cook, 2000; Rich, Young, Fowler,
Wagner, & Black, 1990), particularly among
young men (Beautrais, Fergusson, & Hor-
wood, 2006; Bridges, 2004; Cantor & Slater,
1995; Cheung & Dewa, 2005; Leenaars,
Moksony, Lester, & Wenckstern, 2003; Les-
ter & Leenaars, 1993; Ozanne-Smith, Ashby,
Newstead, Stathakis, & Clapperton, 2004;
Webster, Vernick, Zeoli, & Manganello, 2004).
The Israeli Defense Force (IDF) is a
Gad Lubin, Mordechai Shmushkevitch,
Mark Weiser, and Haim Knobler are with the
Division of Mental Health, Medical Corps, IDF,
Israel; Nomi Webeloff, Demian Halperin, and
Dr. Weiser are affiliated with the Department of
Psychiatry, Sheba Medical Center in Tel Has-
homer, Israel; Dr. Webeloff is also associated with
Ashkelon Academic College, and Dr. Weiser is
with the Sackler School of Medicine at Tel Aviv
Address correspondence to Gad Lubin,
IDF, Division of Mental Health, Medical Corps,
Ramat Gan, Ramat Gan, 52621 Israel; E-mail:
Firearms and Adolescent Suicide Rates
poulation-based army that utilizes mandatory
induction to draft all 18–21-year-old adoles-
cents in the country. Approximately 90% of
all suicides in the IDF are performed using
firearms, and during the years 2003–2005
there were, on average, 28 suicides per year,
of which 26.3 were suicides by firearm. Sui-
cide prevention has become a major priority
of the IDF Mental Health Department, and
considerable efforts have been made to de-
crease rates of suicide in the military.
As Israel is a relatively small country,
many IDF soldiers go home over the week-
end, and took their weapons with them. The
IDF changed its policy in 2006, dictating that
soldiers should leave their weapons at their
bases when headed home for weekend leave.
This policy change was just part of a suicide
prevention program that also included dis-
semination of information regarding suicide
prevention, and a declaration by the IDF
chief of staff that suicide prevention was one
of the major goals of the IDF for that year.
We describe here the impact of this policy,
which reduced availability of firearms while
on leave, on rates of suicide in soldiers aged
18 to 21.
Previous studies have suggested that
although restricted access to firearms is asso-
ciated with decreased rates of suicide, the re-
duction in the rates of suicide by firearms is
offset by increases in suicide by other means,
leading to no overall decrease in suicide rates
(Cheung & Dewa, 2005; Rich et al., 1990;
Sloan et al., 1990). Therefore, we examined
the effect of reduced access to firearms on
suicide by firearms and total suicide rates.
Because the change in policy mostly affected
access to firearms on weekends, we also ex-
amined changes in rates of suicides on week-
ends and weekdays separately.
firearms, suicide during weekends, and sui-
cide during weekdays. Because the policy
change was made in 2006, rates of suicide be-
tween the years 2003–2005 were compared
to those of 2007–2008.
The overall rates of suicide before the
policy change are in line with rates of suicide
in adolescents in this age group (Mann et al.,
2005; Perret et al., 2006; Powell, Fingerhut,
Branche, & Perrotta, 2000). Following the
change in policy total suicide rate decreased
by 40%, from an average of 28 per year dur-
ing 2003–2005 to an average of 16.5 per year
in 2007–2008 (T = 3.35, p = .04). Most of this
decrease in suicide rates was due to a de-
crease in suicide using firearms over the
weekend, from an average of 10 per year
(2003–2005) to an average of 3 per year
(2007–2008) (T = 17.44, p < .001). There
were no significant changes in rates of suicide
We found a 40% decline in the num-
ber of suicides annually after the change of
policy reducing access to firearms during
weekends. This is in line with previous stud-
ies that have found that restricting access to
firearms is effective in decreasing both sui-
cide rates due to firearms and overall suicide
rates (Ozanne-Smith et al., 2004; Webster et
al., 2004). These data clearly emphasize the
effectiveness of decreasing access to firearms
on suicide prevention; the 40% decrease in
rates of suicide is an achievement unparal-
leled by any other means of suicide preven-
tion (Mann et al., 2005).
Contrary to previous studies, we did
not find a compensatory increase in suicide
performed by other means (Cheung & Dewa,
2005; Rich et al., 1990; Sloan et al., 1990).
This might indicate that easy access to fire-
arms might increase rates of impulsive sui-
cide attempts, whereas the need to plan, at
The rates of suicide before and after
the change of policy regarding bringing
home weapons on leave were compared by
independent samples t tests, performed sepa-
rately for total suicide rates, suicides using
Lubin et al. 423
least somewhat, other means of suicide might
deter some from committing suicide.
These data are limited in that they
were collected only in the Israeli military;
however, as the IDF is based on a mandatory
draft, soldiers in the IDF can be considered
to be a population-based sample, and as such
these results should be applicable to other
populations of adolescents. The results of
this study indicate that decreasing access to
firearms can significantly decrease rates of
suicide among adolescents, a finding that
should encourage policy makers to decrease
access to firearms.
of the literature. Medicine, Science, and the Law, 44,
Kapusta, N. D., Etzersdorfer, E., Krall,
C., & Sonneck, G. (2007). Firearm legislation re-
form in the European Union: Impact on firearm
availability, firearm suicide and homicide rates in
Austria. British Journal of Psychiatry, 191, 253–257.
Kellermann, A. L., Rivara, F. P., Somes,
G., Reay, D. T., Francisco, J., Banton, J. G., et
al. (1992). Suicide in the home in relation to gun
ownership. New England Journal of Medicine, 327,
Leenaars, A. A., Moksony, F., Lester, D.,
& Wenckstern, S. (2003). The impact of gun
control (Bill C-51) on suicide in Canada. Death
Studies, 27, 103–124.
Lester, D., & Leenaars, A. (1993). Sui-
cide rates in Canada before and after tightening
firearm control laws. Psychology Reports, 72, 787–
Lewis, G., Hawton, K., & Jones, P.
(1997). Strategies for preventing suicide. British
Journal of Psychiatry, 171, 351–354.
Loftin, C., McDowall, D., Wiersema,
B., & Cottey, T. J. (1991). Effects of restrictive
licensing of handguns on homicide and suicide in
the District of Columbia. New England Journal of
Medicine, 325, 1615–1620.
Ludwig, J., & Cook, P. J. (2000). Impact
of the Brady Act on homicide and suicide rates.
Journal of the American Medical Association, 284,
Mann, J. J., Apter, A., Bertolote, J.,
Beautrais, A., Currier, D., Haas, A., et al.
(2005). Suicide prevention strategies: A systematic
review. Journal of the American Medical Association,
Marzuk, P. M., Leon, A. C., Tardiff, K.,
Morgan, E. B., Stajic, M., & Mann, J. J. (1992).
The effect of access to lethal methods of injury
on suicide rates. Archives of General Psychiatry, 49,
Miller, M., Azrael, D., & Hemenway, D.
(2002). Household firearm ownership and suicide
rates in the United States. Epidemiology, 13, 517–
Beautrais, A. L., Fergusson, D. M., &
Horwood, L. J. (2006). Firearms legislation and
reductions in firearm-related suicide deaths in
New Zealand. Austialia New Zealand Journal of
Psychiatry, 40, 253–259.
Brent, D. A., Perper, J. A., Allman, C. J.,
Moritz, G. M., Wartella, M. E., & Zelenak,
J. P. (1991). The presence and accessibility of fire-
arms in the homes of adolescent suicides: A case-
control study. Journal of the American Medical Asso-
ciation, 266, 2989–2995.
Brent, D. A., Perper, J. A., Moritz, G.,
Baugher, M., Schweers, J., & Roth, C. (1993).
Firearms and adolescent suicide: A community
case-control study. American Journal of Diseases of
Children, 147, 1066–1071.
Bridges, F. S. (2004). Gun control law
(Bill C-17), suicide, and homicide in Canada. Psy-
chological Reports, 94, 819–826.
Cantor, C. H., & Slater, P. J. (1995).
The impact of firearm control legislation on sui-
cide in Queensland: Preliminary findings. Medical
Journal of Australia, 162, 583–585.
Caron, J. (2004). Gun control and suicide:
Possible impact of Canadian legislation to ensure
safe storage of firearms. Archives of Suicide Re-
search, 8, 361–374.
Carrington, P. J., & Moyer, S. (1994).
Gun control and suicide in Ontario. American
Journal of Psychiatry, 151, 606–608.
Cheung, A. H., & Dewa, C. S. (2005).
Current trends in youth suicide and firearms regu-
lations. Canadian Journal of Public Health, 96, 131–
Goldney, R. D. (2006). Suicide in Austra-
lia: Some good news. Medical Journal of Australia,
Grossman, D. C., Mueller, B. A., Riedy,
C., Dowd, M. D., Villaveces, A., Prodzinski, J.,
et al. (2005). Gun storage practices and risk of
youth suicide and unintentional firearm injuries.
Journal of the American Medical Association, 293,
Haw, C., Sutton, L, Simkin, S., Gunnell,
D., Kapur, N., Nowers, M., et al. (2004). Sui-
cide by gunshotin the United Kingdom: A review
Firearms and Adolescent Suicide Rates
Miller, M., Hemenway, D., & Azrael, D.
(2004). Firearms and suicide in the northeast.
Journal of Trauma, 57, 626–632.
Miller, M., Lippmann, S. J., Azrael, D.,
& Hemenway, D. (2007). Household firearm
ownership and rates of suicide across the 50
United States. Journal of Trauma, 62, 1029–1035.
Ozanne-Smith, J., Ashby, K., Newstead,
S., Stathakis, V. Z., & Clapperton, A. (2004).
Firearm related deaths: The impact of regulatory
reform. Injury Prevention, 10, 280–286.
Perret, G., Abudureheman, A., Perret-
Catipovic, M., Flomenbaum, M., & La Harpe,
R. (2006). Suicides in the young people of Ge-
neva, Switzerland, from 1993 to 2002. Journal of
Forensic Science, 51, 1169–1173.
Powell, K. E., Fingerhut, L. A., Branche,
C. M., & Perrotta, D. M. (2000). Deaths due to
injury in the military. American Journal of Preven-
tive Medicine, 18, 26–32.
Rich, C. L., Young, J. G., Fowler, R. C.,
Wagner, J., & Black, N. A. (1990). Guns and sui-
cide: Possible effects of some specific legislation.
American Journal of Psychiatry, 147, 342–346.
Shenassa, E. D., Rogers, M. L., Spalding,
K. L., & Roberts, M. B. (2004). Safer storage of
firearms at home and risk of suicide: A study of
protective factors in a nationally representative
sample. Journal of Epidemiology and Community
Health, 58, 841–848.
Shields, L. B., Hunsaker, D. M., &
Hunsaker, III, J. C. (2006). Adolescent and young
adult suicide: A 10-year retrospective review of
Kentucky medical examiner cases. Journal of Fo-
rensic Science, 51, 874–879.
Singh, V. D., & Lathrop, S. L. (2008).
Youth suicide in New Mexico: A 26-year retro-
spective review. Journal of Forensic Science, 53,
Sloan, J. H., Rivara, F. P., Reay, D. T.,
Ferris, J. A., & Kellermann, A. L. (1990). Fire-
arm regulations and rates of suicide: A comparison
of two metropolitan areas. New England Journal of
Medicine, 322, 369–373.
Webster, D. W., Vernick, J. S., Zeoli,
A. M., & Manganello, J. A. (2004). Association
between youth-focused firearm laws and youth
suicides. Journal of the American Medical Associa-
tion, 292, 594–601.
Manuscript Received: July 23, 2009
Revision Accepted: July 23, 2009