Special Article
Firearm Regulations and Rates of Suicide — A Comparison of Two Metropolitan Areas
N Engl J Med 1990; 322:369-373February 8, 1990
- Abstract
- Abstract
To investigate a possible association between firearm regulations and suicide, we compared the incidence of suicide from 1985 through 1987 in King County, Washington, with that in the Vancouver metropolitan area, British Columbia, where firearm regulations are more restrictive.
The risk of death from suicide was not found to differ significantly between King County and the Vancouver area (relative risk, 0.97; 95 percent confidence interval, 0.87 to 1.09). The rate of suicide by firearms, however, was higher in King County (relative risk, 2.34; 95 percent confidence interval, 1.90 to 2.88), because the rate of suicide by handguns was 5.7 times higher there. The difference in the rates of suicide by firearms was offset by a 1.5-fold higher rate of suicide by other means in the Vancouver area. Persons 15 to 24 years old had a higher suicide rate in King County than in the Vancouver area (relative risk, 1.38; 95 percent confidence interval, 1.02 to 1.86). Virtually all the difference was due to an almost 10-fold higher rate of suicide by handguns in King County.
We conclude that restricting access to handguns might be expected to reduce the suicide rate in persons 15 to 24 years old, but that it probably would not reduce the overall suicide rate. (N Engl J Med 1990; 322:369–73.)
Media in This Article
Table 1
Socioeconomic Characteristics and Ethnic Composition of King County and the Vancouver Metropolitan Area.*Table 2
Annual Suicide Rates According to Cause of Death in the Study Areas, 1985 through 1987.*Article Activity
- Article
SUICIDE is a major public health problem in the United States. In 1980 nearly 27,000 persons took their own lives, making suicide the 10th most common cause of death overall and the third most common cause among adolescents and young adults.1 Given that 57 percent of the cases of suicide in the United States involve firearms,2 much attention has been focused on the relation between the availability of firearms and the rates of suicide in communities. Citing the frequently impulsive nature of suicidal urges and the high case-fatality rate from injuries inflicted by firearms as compared with other methods of suicide, some persons have urged gun control as a means of reducing suicide rates.3 , 4
One method of evaluating the potential effect of gun-control laws on suicide rates in the United States is through comparisons with the situation in other countries. However, such comparisons of suicide rates and degrees of gun control are usually flawed because of the presence of many differing socioeconomic, cultural, and behavioral factors.
We studied the relation between firearm regulations and rates of suicide in two urban areas of the Pacific Northwest: King County, Washington, and the Vancouver metropolitan area, British Columbia. Although these two areas are similar in many ways, they have taken very different approaches to the regulation of handguns.
Methods
Study Sites
King County, Washington, and the Vancouver metropolitan area, British Columbia, are major port areas in the Pacific Northwest. Although on opposite sides of an international border, they are only 225 km (140 miles) apart, a three-hour drive by freeway. They share a common geography, climate, and history. Citizens in both areas share very similar rates of unemployment, marriage, and mobility. The median income in U.S. dollars of households in King County exceeded that of their counterparts in the Vancouver area by only $229 in the most recent censuses that are directly comparable. The percentages of the households in both areas that earn less than $10,000 U.S. dollars annually are similar (Table 1Table 1
Socioeconomic Characteristics and Ethnic Composition of King County and the Vancouver Metropolitan Area.*).5 6 7 8 The two communities also share similar cultural values. Six of the nine most popular television programs in King County are also among the nine most-watched programs in the Vancouver area.9 , 10 Ethnically, both areas have substantial white majorities; although the Vancouver area has a larger Asian population, King County has a higher proportion of black and Hispanic residents (Table 1).5 , 6
Firearm Regulations
Despite their similarities, King County and the Vancouver area differ markedly in their approach to the regulation of firearms. In King County, handguns may be purchased legally for use in self-defense. There is a 7-day waiting period before a handgun may be purchased for use in the home and a 30-day waiting period before a permit can be issued to carry a handgun as a concealed weapon in public. The recreational uses of handguns are minimally restricted.11
In the Vancouver metropolitan area (a group of townships defined by Statistics Canada for statistical and census purposes), self-protection is not considered a legal or valid reason for purchasing a handgun, except in rare cases. Concealed weapons cannot be carried in public. The recreational uses of handguns, such as shooting at targets or maintaining a gun collection, are regulated by the province and require a restricted-weapons permit. A permit must also be obtained to transport a handgun to a shooting club. Handguns can be transported by car, but they must be stored in a locked box in the trunk during transit.12 , 13
Hunting is popular in both areas. In the Vancouver area, rifles and shotguns need not be registered, but they require a certificate to be purchased. In King County, rifles and shotguns require no registration or certificate for purchase.
Determination of Gun Ownership
The prevalence of firearm ownership was assessed by two methods independently. First, we obtained from the Chief Provincial Firearm Office of British Columbia the total number of registrations for restricted weapons issued to people in the Vancouver area from April 1985 through March 1986 and compared this figure (2037) with the total number (3596) of persons in King County who bought handguns for the first time from commercial dealers during the same period, according to sales records obtained from the Office of Business and Professions Administration of the Department of Licensing of the State of Washington. In the Vancouver area, 95 percent of the restricted-weapons registrations were issued for the ownership of handguns. Second, we used Cook's gun-prevalence index — an index developed and validated in 49 U.S. cities over a period of 12 years that is highly correlated with regional surveys of firearm ownership and is believed to be a valid indicator of differences between cities with respect to the prevalence of firearm ownership.14 The gun-prevalence index for King County is 45.4, and that for the Vancouver area is 20.5. Both indirect estimates suggested that there were more handguns available in King County than in the Vancouver area. Data about specific rates of gun ownership in either community have never been collected by a direct survey.
Case Identification
We identified all known cases of suicide in King County and the Vancouver metropolitan area from January 1, 1985, through December 31, 1987. Using the files of the medical examiners, we ascertained the age, sex, and race of the victims and the method of suicide.
The population-based rates of suicide per 100,000 persons were then compared. The rates were adjusted when possible for any differences in age and sex. Relative risks and 95 percent confidence intervals were calculated by the maximum-likelihood method of estimation, on the basis of a comparison of the rates in King County and the Vancouver area.15
Results
During the three-year study period, there were 618 suicides in King County (15.12 per 100,000 person-years). In the Vancouver area, there were 644 suicides during the same period (15.55 per 100,000 person-years). After adjustment for differences between the populations with respect to age and sex, the relative risk of a completed suicide attempt in King County as compared with the Vancouver area was found to be 0.97 (95 percent confidence interval, 0.87 to 1.09).
When the cases of suicide were subdivided according to the cause of death, the rate of suicide by firearms was found to be significantly higher in King County than in the Vancouver area. The difference was entirely due to a 5.7-fold higher rate of suicide involving handguns in King County. However, this difference was offset by a 1.5-fold higher rate of suicide by means other than firearms in the Vancouver area (Table 2Table 2
Annual Suicide Rates According to Cause of Death in the Study Areas, 1985 through 1987.*). There appeared to be little difference between these two areas in the rate of suicide involving rifles or shotguns.In both communities, approximately 70 percent of the suicides involved males. When the rates were stratified by age, the risk was lowest in persons 14 years old or under and highest in those over 45 (Table 3Table 3
Rates and Relative Risks of Suicide in the Study Areas, 1985 through 1987, According to Age.*). In all but the 15-to-24-year-old and the 35-to-44-year-old age groups, the age-specific suicide rates in the two areas were comparable. However, King County residents in the 15-to-24-year-old age group committed suicide at a rate 1.38 times that of Vancouver-area residents of the same age. Virtually the entire difference was due to an almost 10-fold higher rate of suicide involving handguns (Table 4Table 4
Suicide Rates in the Study Areas among Persons 15 to 24 Years of Age, 1985 through 1987, According to Cause of Death.*).When the cases of suicide were stratified by race, whites in both areas were found to have similar rates of suicide (Table 5Table 5
Crude Suicide Rates and Relative Risks of Suicide in the Study Areas, 1985 through 1987, According to Race or Ethnic Group.*). The Asians in King County had higher rates than those in the Vancouver area, and the blacks, Hispanics, and Native Americans in the Vancouver area had higher rates than their counterparts in King County. However, given the relatively small number of members of these minority groups in the population, the only statistically significant difference was the higher rate among Native Americans in the Vancouver metropolitan area as compared with their counterparts in King County.Discussion
Although many have addressed the psychological and behavioral aspects of the pathogenesis of suicide, increasing attention has recently been given to the possible effectiveness of interventions aimed at modifying or restricting access to common means of suicide, particularly firearms. Firearms are an increasingly common means of suicide and account for the highest proportion of suicides in the United States.1 Boyd has correlated the increasing rates of suicide nationally with the greater availability of handguns and has suggested that the rates of suicide in the United States might be decreased by restricting the sale of such weapons.4 If suicides are commonly impulsive acts, the restriction of access to highly lethal weapons (such as firearms) might be expected to decrease the suicide rate. If, on the other hand, the choice of a firearm has less to do with the availability of a weapon than with the strength of the intention, persons determined to commit suicide will only work harder to obtain a gun or decide to kill themselves by other means. Several studies have shown that eliminating a common means of suicide has often been followed by an increase in the rates of suicide by other means. For example, when coal gas was eliminated from domestic gas supplies in Basel, Switzerland,16 and Australia,17 the decreased rate of suicide by this method was offset by higher rates of suicide by other means. However, after the elimination of coal gas in England and Wales, the rate of suicide by other means increased only among men 15 to 34 years of age; for older men and for women, the decline in the rates of suicide by coal gas was paralleled by an overall decline in suicide rates.18
To examine the effect of the availability of firearms on the rates of suicide in communities, we studied two large, socioeconomically similar populations in the Pacific Northwest that had different approaches to gun control. In the aggregate, these two populations represented 8.2 million person-years of risk.
We found a strong positive association in these communities between the rates of handgun ownership and the rates of suicide by firearms. This finding is consistent with the observations of others.19 Neither King County nor the Vancouver metropolitan area substantially restricts access to rifles or shotguns, and in both communities the rates of suicide involving these classes of weapons were virtually the same. Access to handguns, on the other hand, is much more closely restricted in the Vancouver area, a policy that was associated with a rate of suicide by handguns less than one fifth that of King County.
This lower-than-expected rate of suicide by handguns was entirely offset, however, by a rate of suicide by other means in the Vancouver area that was proportionately higher than that in King County. This observation suggests that most persons who were intent on committing suicide simply substituted another method. As a result, a slight restriction in access to handguns was not found to be associated with any appreciable difference in the overall rate of suicide in the community.
In the United States, suicide among teenagers has attracted increasing attention in recent years. Several studies have suggested that in this age group suicide is more frequently an impulsive act than it is among older persons.20 We did find that among teenagers ready access to handguns was associated with a somewhat higher rate of suicide. This difference was accounted for almost entirely by a 9.6-fold higher rate of suicide by handguns among King County residents 15 to 24 years of age; this higher rate was not entirely offset by the higher rates of suicide by other means among similar residents in the Vancouver area. On the other hand, we also noted a higher overall rate of suicide among Vancouver-area residents 35 to 44 years of age — an observation for which there is no ready explanation.
Racial differences in suicide rates may be prone to confounding by rates of unemployment, other socioeconomic differences, or both. Overall, socioeconomic status appears comparable in these two communities, but it is not necessarily similar in each racial or ethnic group. In the United States, suicide rates vary according to race1 but show little variation with respect to per capita income.2
Four limitations of our study warrant comment. First, the study was based on comparisons between two communities that are largely comparable but politically distinct. Aggregate analyses of this type may not identify all the possible differences between the two populations. For example, alcoholism, psychiatric illness, and unemployment have been associated with a higher risk of suicide.21 , 22 Higher rates of such factors in the Vancouver area could increase that community's suicide rate relative to King County and obscure the small benefits from gun control. We believe that any such confounding effects were probably small.
Second, the study was based on two largely urban populations in the Pacific Northwest, and therefore its results may not be generalizable to other communities in North America. Proportionally, firearms are used in only 44 percent of the suicides in King County, as compared with 57 percent of suicides in the United States overall.1
Third, the calculation of suicide rates according to cause in each community depended on the accurate and complete ascertainment of all cases of suicide that occurred during the study period. The determination of cause of death and intent was based on a careful review of the autopsy and toxicologic findings and the results of investigations by the office of the medical examiner or coroner. Both study areas had comparably low (approximately 5 percent) rates of death of undetermined cause. Thus, we considered the criteria for the determination of suicide according to method to be valid and similar in each jurisdiction.
Finally, the measures of firearm ownership in these two communities were estimates and were not directly comparable. For example, in King County multiple sales of handguns to the same person in a given year are entered under one record. In the Vancouver area, such sales would require separate applications. As a result, the figures for handgun prevalence in the Vancouver area may be somewhat inflated relative to those for King County. Cook's gun-prevalence index has been shown to correlate with data derived from national surveys made in the United States, but the correlation has not been validated in Vancouver or elsewhere outside the United States.
The use of aggregate data to derive causal inferences about individual risk has well-known limitations. It is to be hoped that future studies will be able to employ more powerful methods to assess a person's risk of suicide in relation to a variety of potential risk factors, including firearm ownership.
In contrast to our findings of the limited effect of gun control on overall community rates of suicide, our earlier study found large differences in the rates of homicide in the same two communities.23 These were entirely due to a 4.8-fold higher risk of receiving a fatal wound from a handgun in Seattle as compared with Vancouver. The rates of homicide by means other than firearms were nearly identical. Taken together, these data suggest that gun control, and therefore the availability of guns, may have an effect on the rate of homicide in the community, but little effect on the overall rate of suicide. The reasons for this difference are unknown. It may be that persons intent on self-destruction are sufficiently determined that they will switch to another lethal means if denied access to a firearm. In many cases, homicide may be a more impulsive act, and fatal outcomes may therefore be averted more often if highly lethal means are less readily available. This question deserves careful scrutiny in future studies.
Persons considering the potential effect of handgun regulations on the rates of violent death should bear in mind that whereas limiting access to handguns may have little effect on the overall suicide rate in a community, it may have a substantially greater effect on the rate of homicide. Nor should the small but significant association of gun control with lower rates of suicide in the 15-to-24-year-old age group be ignored. Our results suggest that for this age group, restricting access to handguns may have some benefit.
Access to a lethal means of injuring oneself appears to be just one strand in the web of events that can lead to suicide. Further research is needed to define more clearly the complex interaction of behavior, experience, and environment in the pathogenesis of suicide and homicide.
Supported by a grant (CCRO-02570–02) from the Centers for Disease Control.
Source Information
From the Departments of Pediatrics (F.P.R.), Epidemiology (F.P.R.), and Pathology (D.T.R.), University of Washington, Seattle; the Harborview Injury Prevention and Research Center, Seattle (J.H.S., F.P.R., D.T.R.); the King County Medical Examiner's Office, Seattle (D.T.R.); the Division of Plastic Surgery and Rehabilitation Medicine, Stanford University, Stanford, Calif. (J.H.S.); the Department of Forensic Pathology, University of British Columbia, Vancouver (J.A.J.F.); and the Department of Medicine, University of Tennessee. Memphis (A.L.K.). Address reprint requests to Dr. Rivara at the Harborview Injury Prevention and Research Center, Harborview Medical Center, Mailstop ZX-10, 325 Ninth Ave., Seattle, WA 98104.
- References
References
1
Suicide surveillance: 1970–80. Atlanta: Centers for Disease Control, 1985.
2
Baker SP, O'Neill B, Karpf RS. The injury fact book. Lexington, Mass.: Lexington Books, 1984.
3
Baker
CrossRef | Web of Science | Medline4
Boyd
Full Text | Web of Science | Medline5
Bureau of Census. 1980 census of population. Washington, D.C.: Government Printing Office, 1981.
6
Statistics Canada. 1981 and 1986 census of Canada, Vancouver: metropolitan area, British Columbia. Ottawa, Ont.: Minister of Supply and Services, 1983 and 1987.
7
Idem. The labour force annual average, 1981. Ottawa, Ont.: Statistics Canada, 1981. (Catalogue 71n-529.)
8
Office of Financial Management, Forecasting Division. 1986 population trends for Washington State. Olympia, Wash., 1988.
9
Seattle local market T.V. ratings, 1985–86. (Based on Arbitron television ratings.) Provided by KING TV, Seattle, Wash.
10
Vancouver local market T.V. ratings, 1985–86. Provided by Bureau of Broadcast Measurement, Toronto.
11
Revised Code of State of Washington. RCW chapter 9.41.090, 9.41.095, 9.41.070, 1986.
12
Criminal Code of Canada. Firearms and other offensive weapons, Martins Criminal Code of Canada, 1982. Part II.1. (Sections 81–016.9, 1982.)
13
Idem. Restricted Weapons and Firearm Control Regulations, Sec. 106.2 (11); Amendment Act, July 18, 1977, 1982.
14
Cook PJ. The role of firearms in violent crime. In: Wolfgang ME, Weiner NA, eds. Criminal violence. Beverly Hills, Calif.: Sage, 1982:236–90.
15
Rothman KJ, Boice JD Jr. Epidemiologic analysis with a programmable calculator. Boston: Epidemiology Resources, 1982.
16
Stengel S. Suicide and attempted suicide. Baltimore: Penguin, 1964:34–5.
17
Burvill
CrossRef | Web of Science | Medline18
Kreitman
Medline19
Markush
CrossRef | Web of Science | Medline20
Rich
Web of Science | Medline21
Barraclough
CrossRef | Web of Science | Medline22
Platt S. Suicide behaviour and unemployment: a literature review. In: Westcott G, Svensson P-G, Zöllner HFK, eds. Health policy implications of unemployment. Copenhagen: World Health Organization, 1985:87–132.
23
Sloan
Full Text | Web of Science | Medline
- Citing Articles (66)
Citing Articles
1
Mark Duggan, Randi Hjalmarsson, Brian A. Jacob. (2011) The Short-Term and Localized Effect of Gun Shows: Evidence from California and Texas. Review of Economics and Statistics 93:3, 786-799
CrossRef2
Gary Kleck, Tomislav Kovandzic, Mark Saber, Will Hauser. (2011) The effect of perceived risk and victimization on plans to purchase a gun for self-protection. Journal of Criminal Justice 39:4, 312-319
CrossRef3
Seong Yi Kim, Myoung-Hee Kim, Ichiro Kawachi, Youngtae Cho. (2011) Comparative Epidemiology of Suicide in South Korea and Japan: Effects of Age, Gender and Suicide Methods. Crisis: The Journal of Crisis Intervention and Suicide Prevention 32:1, 5-14
CrossRef4
Gad Lubin, Nomi Werbeloff, Demian Halperin, Mordechai Shmushkevitch, Mark Weiser, Haim Y. Knobler. (2010) Decrease in Suicide Rates After a Change of Policy Reducing Access to Firearms in Adolescents: A Naturalistic Epidemiological Study. Suicide and Life-Threatening Behavior 40:5, 421-424
CrossRef5
Niranjan S. Karnik, Hans Steiner. (2007) Evidence for Interventions for Young Offenders. Child and Adolescent Mental Health 12:4, 154-159
CrossRef6
M. Humeau, N. Papet, N. Jaafari, L. Gotzamanis, N. Lafay, J.-L. Senon. (2007) Disponibilité des armes à feu et risque suicidaire: revue de la littérature. Annales Médico-psychologiques, revue psychiatrique 165:4, 269-275
CrossRef7
Matthew Miller, Steven J. Lippmann, Deborah Azrael, David Hemenway. (2007) Household Firearm Ownership and Rates of Suicide Across the 50 United States. The Journal of Trauma: Injury, Infection, and Critical Care 62:4, 1029-1035
CrossRef8
Melanie A. Dirks, Teresa A. Treat, V. Robin Weersing. (2007) Integrating theoretical, measurement, and intervention models of youth social competence. Clinical Psychology Review 27:3, 327-347
CrossRef9
Guillaume Perret, Abliz Abudureheman, Maja Perret-Catipovic, Mark Flomenbaum, Romano La Harpe. (2006) Suicides in the Young People of Geneva, Switzerland, From 1993 to 2002. Journal of Forensic Sciences 51:5, 1169-1173
CrossRef10
Antoon A. Leenaars. (2006) Suicide by shooting and gun ownership (licenses) in Austria: would gun restriction help?. Wiener klinische Wochenschrift 118:15-16, 439-441
CrossRef11
Lisa B.E. Shields, Donna M. Hunsaker, John C. Hunsaker. (2006) Adolescent and Young Adult Suicide: A 10-Year Retrospective Review of Kentucky Medical Examiner Cases. Journal of Forensic Sciences 51:4, 874-879
CrossRef12
Jeffrey A. Bridge, Tina R. Goldstein, David A. Brent. (2006) Adolescent suicide and suicidal behavior. Journal of Child Psychology and Psychiatry 47:3-4, 372-394
CrossRef13
A. L. Beautrais, D. M. Fergusson, L. J. Horwood. (2006) Firearms legislation and reductions in firearm-related suicide deaths in New Zealand. Australian and New Zealand Journal of Psychiatry 40:3, 253-259
CrossRef14
Jean Lemaire. (2005) The Cost of Firearm Deaths in the United States: Reduced Life Expectancies and Increased Insurance Costs. Journal of Risk <html_ent glyph="@amp;" ascii="&"/> Insurance 72:3, 359-374
CrossRef15
Naomi Duke, Michael D. Resnick, Iris Wagman Borowsky. (2005) Adolescent firearm violence: Position paper of the Society for Adolescent Medicine. Journal of Adolescent Health 37:2, 171-174
CrossRef16
Thomas Reisch, Konrad Michel. (2005) Securing a Suicide Hot Spot: Effects of a Safety Net at the Bern Muenster Terrace. Suicide and Life-Threatening Behavior 35:4, 460-467
CrossRef17
Linda L Dahlberg, Alexander Butchart. (2005) State of the science: violence prevention efforts in developing and developed countries. International Journal of Injury Control and Safety Promotion 12:2, 93-104
CrossRef18
Jean Caron. (2004) Gun Control and Suicide: Possible Impact of Canadian Legislation to Ensure Safe Storage of Firearms. Archives of Suicide Research 8:4, 361-374
CrossRef19
C. C. Branas, M. L. Nance, M. R. Elliott, T. S. Richmond, C. W. Schwab. (2004) Urban-Rural Shifts in Intentional Firearm Death: Different Causes, Same Results. American Journal of Public Health 94:10, 1750-1755
CrossRef20
Kenneth R Conner, Yueying Zhong. (2003) State firearm laws and rates of suicide in men and women. American Journal of Preventive Medicine 25:4, 320-324
CrossRef21
MADELYN S. GOULD, TED GREENBERG, DREW M. VELTING, DAVID SHAFFER. (2003) Youth Suicide Risk and Preventive Interventions: A Review of the Past 10 Years. Journal of the American Academy of Child & Adolescent Psychiatry 42:4, 386-405
CrossRef22
Mirjana Grubišić-Ilić, Dragica Kozarić-Kovačić, Frane Grubišić, Zrnka Kovačić. (2002) Epidemiological study of suicide in the Republic of Croatia – comparison of war and post-war periods and areas directly and indirectly affected by war. European Psychiatry 17:5, 259-264
CrossRef23
Matthew Miller, Deborah Azrael, David Hemenway. (2002) Household Firearm Ownership and Suicide Rates in the United States. Epidemiology 13:5, 517-524
CrossRef24
Jayanti Chotai, Ellinor Salander Renberg, Lars Jacobsson. (2002) Method of Suicide in Relation to Some Sociodemographic Variables in Northern Sweden. Archives of Suicide Research 6:2, 111-122
CrossRef25
Marina Catallozzi, Jonathan R. Pletcher, Donald F. Schwarz. (2001) Prevention of suicide in adolescents. Current Opinion in Pediatrics 13:5, 417-422
CrossRef26
Johanna Birckmayer, David Hemenway. (2001) Suicide and Firearm Prevalence: Are Youth Disproportionately Affected?. Suicide and Life-Threatening Behavior 31:3, 303-310
CrossRef27
Madelyn S. Gould, Rachel A. Kramer. (2001) Youth Suicide Prevention. Suicide and Life-Threatening Behavior 31:Supplement to I, 6-31
CrossRef28
R. S. Spicer, T. R. Miller. (2000) Suicide acts in 8 states: incidence and case fatality rates by demographics and method. American Journal of Public Health 90:12, 1885-1891
CrossRef29
Peter Cummings. (2000) Should Your Neighbor Buy a Gun?. Epidemiology 11:6, 617-619
CrossRef30
Matthew Miller, Deborah Azrael, David Hemenway. (2000) Community Firearms, Community Fear. Epidemiology 11:6, 709-714
CrossRef31
DAVID A. BRENT, MARIANNE BAUGHER, BORIS BIRMAHER, DAVID J. KOLKO, JEFF BRIDGE. (2000) Compliance With Recommendations to Remove Firearms in Families Participating in a Clinical Trial for Adolescent Depression. Journal of the American Academy of Child & Adolescent Psychiatry 39:10, 1220-1226
CrossRef32
M MILLER, D HEMENWAY. (2000) The relationship between firearms and suicideA review of the literature. Aggression and Violent Behavior 4:1, 59-75
CrossRef33
Victor C. Strasburger. (2000) GETTING TEENAGERS TO SAY NO TO SEX, DRUGS, AND VIOLENCE IN THE NEW MILLENNIUM. Medical Clinics of North America 84:4, 787-810
CrossRef34
Seema Shah, Richard E Hoffman, Lane Wake, William M Marine. (2000) Adolescent suicide and household access to firearms in Colorado: results of a case-control study. Journal of Adolescent Health 26:3, 157-163
CrossRef35
Jane M. Burns, George C. Patton. (2000) Preventive interventions for youth suicide: A risk factor-based approach. Australian and New Zealand Journal of Psychiatry 34:3, 388-407
CrossRef36
Wintemute, Garen J., Parham, Carrie A., Beaumont, James Jay, Wright, Mona, Drake, Christiana, . (1999) Mortality among Recent Purchasers of Handguns. New England Journal of Medicine 341:21, 1583-1589
Full Text37
Louis E Christie. (1999) Australian gun controls: Should more be done?. Emergency Medicine Australasia 11:2, 94-100
CrossRef38
Keith A. King. (1999) Fifteen Prevalent Myths Concerning Adolescent Suicide. Journal of School Health 69:4, 159-161
CrossRef39
L FREED. (1998) PREVENTION OF FIREARM-RELATED INJURIES AND DEATHS AMONG YOUTHA Product-Oriented Approach. Pediatric Clinics of North America 45:2, 427-438
CrossRef40
C BELL, D CLARK. (1998) ADOLESCENT SUICIDE. Pediatric Clinics of North America 45:2, 365-380
CrossRef41
M.Elizabeth Sandel, Kathleen R. Bell, Linda J. Michaud. (1998) 1. Traumatic brain injury: Prevention, pathophysiology, and outcome prediction. Archives of Physical Medicine and Rehabilitation 79:3, S3-S9
CrossRef42
Brace W. Goldberg. (1998) Preventing Firearm Violence. Journal of Aggression, Maltreatment & Trauma 1:2, 99-111
CrossRef43
Firearms Task Force. (1998) Consensus statement on youth suicide by firearms. Archives of Suicide Research 4:1, 89-94
CrossRef44
Jane L. Pearson. 1998. Suicidal Behavior in Late Life. , 247-266.
CrossRef45
Yoshitomo Takahashi, Hideto Hirasawa, Keiko Koyama. (1998) Restriction of suicide methods: A japanese perspective. Archives of Suicide Research 4:1, 101-107
CrossRef46
James C. Anthony, Michelle L. Van Etten. 1998. Epidemiology and its Rubrics. , 355-390.
CrossRef47
Israel Orbach. (1997) A Taxonomy of Factors Related to Suicidal Behavior. Clinical Psychology: Science and Practice 4:3, 208-224
CrossRef48
Y CONWELL. (1997) MANAGEMENT OF SUICIDAL BEHAVIOR IN THE ELDERLY. Psychiatric Clinics of North America 20:3, 667-683
CrossRef49
T Miller. (1997) Costs of gunshot and cut/stab wounds in the United States, with some Canadian comparisons. Accident Analysis & Prevention 29:3, 329-341
CrossRef50
Jukka Hintikka, Johannes Lehtonen, Heimo Viinamäki. (1997) Hunting guns in homes and suicides in 15--24--year-old males in Eastern Finland. Australian and New Zealand Journal of Psychiatry 31:6, 858-861
CrossRef51
Debra K. Hunt. (1996) Preventing firearm violence. Journal of General Internal Medicine 11:11, 694-701
CrossRef52
ANNAKATRI OHBERG, JOUKO LONNQVIST, SEPPO SARNA, ERKKI VUORI. (1996) Violent Methods Associated with High Suicide Mortality among the Young. Journal of the American Academy of Child & Adolescent Psychiatry 35:2, 144-153
CrossRef53
Michael Dudley, Chris Cantor, Greg de Moore. (1996) Jumping the gun: firearms and the mental health of Australians. Australian and New Zealand Journal of Psychiatry 30:3, 370-381
CrossRef54
C. Vecchia, F. Lucchini, F. Levi. (1994) Worldwide trends in suicide mortality, 1955?1989. Acta Psychiatrica Scandinavica 90:1, 53-64
CrossRef55
(1994) Guns in the Home. New England Journal of Medicine 330:16, 1157-1159
Full Text56
E Y Deykin, S L Buka. (1994) Suicidal ideation and attempts among chemically dependent adolescents.. American Journal of Public Health 84:4, 634-639
CrossRef57
Tiepu Liu, John W. Waterbor. (1994) Comparison of suicide rates among industrial groups. American Journal of Industrial Medicine 25:2, 197-203
CrossRef58
G. Sonneck, E. Etzersdorfer, S. Nagel-Kuess. (1994) Imitative suicide on the Viennese subway. Social Science & Medicine 38:3, 453-457
CrossRef59
Tiepu Liu, John W. Waterbor. (1994) Declining Use of Firearms to Commit Suicide in Alabama in the 1980s. OMEGA--Journal of Death and Dying 30:2, 145-153
CrossRef60
(1992) Suicide in the Home in Relation to Gun Ownership. New England Journal of Medicine 327:26, 1878-1881
Full Text61
Kellermann, Arthur L., Rivara, Frederick P., Somes, Grant, Reay, Donald T., Francisco, Jerry, Banton, Joyce Gillentine, Prodzinski, Janice, Fligner, Corinne, Hackman, Bela B., . (1992) Suicide in the Home in Relation to Gun Ownership. New England Journal of Medicine 327:7, 467-472
Full Text62
Winokur, George, Black, Donald W., . (1992) Suicide — What Can Be Done?. New England Journal of Medicine 327:7, 490-491
Full Text63
(1992) Effects of Restrictive Handgun Laws. New England Journal of Medicine 326:17, 1157-1161
Full Text64
Kassirer, Jerome P., . (1991) Firearms and the Killing Threshold. New England Journal of Medicine 325:23, 1647-1650
Full Text65
Loftin, Colin, McDowall, David, Wiersema, BrianCottey, Talbert J., . (1991) Effects of Restrictive Licensing of Handguns on Homicide and Suicide in the District of Columbia. New England Journal of Medicine 325:23, 1615-1620
Full Text66
(1990) Firearm Regulations and Rates of Suicide. New England Journal of Medicine 323:2, 136-137
Full Text
