Correspondence

Firearms and Suicide

N Engl J Med 2000; 342:1528-1529May 18, 2000

Article

To the Editor:

The article by Wintemute et al. (Nov. 18 issue)1 and the accompanying editorial by Rosenberg et al.2 add to the public health literature on firearms. Rosenberg et al. note that we need more information about the circumstances in which suicide with the use of firearms occurs. Clinical studies can complement an epidemiologic approach to help provide such information. One clinical method is to conduct comprehensive interviews with persons who have survived serious suicide attempts involving firearms, in order to determine the psychiatric diagnosis, personality profile, motivation for the attempt, and precipitating factors. These studies illustrate several points.3

First, shootings are often preceded by a crescendo of disputes with an intimate partner, the attempts are often not well planned, and the patients tend to abuse alcohol. These patients are rarely psychotic but have serious domestic and personality problems, often of an antisocial nature.

Second, the fact that the attempts are often impulsive can give the incorrect impression that these are well-adjusted persons who, against the flow of their lives, shot themselves. In fact, long-term clinical history shows that there is a more complicated pattern of long-standing problems and that the suicide attempt was one of several forms of self-destructive behavior.

Finally, a clinical perspective sheds light on prevention. This has implications for the proposed background screening checks before a person can purchase a firearm. A screening process that identifies only admission to a psychiatric unit or documented severe illness such as psychosis will almost certainly not identify a subgroup of persons at high risk. The California procedure rightly casts the net more broadly, attempting to identify persons with substance abuse and a record of violent misdemeanors. Nonetheless, the clinical studies indicate that even this approach is likely to be insufficient to identify the many people with domestic problems, involvement in custody battles, and alcohol-related problems that may not be severe enough to come to the attention of public authorities but that predispose them to the use of firearms for suicide attempts.

Gregory M. de Moore, M.B., B.S.
Andrew R. Robertson, M.B., B.S.
Westmead Hospital, Sydney, NSW 2145, Australia

3 References

1. 1

   Wintemute GJ, Parham CA, Beaumont JJ, Wright M, Drake C. Mortality among recent purchasers of handguns. N Engl J Med 1999;341:1583-1589
   Full Text | Web of Science | Medline

2. 2

   Rosenberg ML, Mercy JA, Potter LB. Firearms and suicide. N Engl J Med 1999;341:1609-1611
   Full Text | Web of Science | Medline

3. 3

   de Moore GM, Robertson AR. Suicide attempts by firearms and by leaping from heights: a comparative study of survivors. Am J Psychiatry 1999;156:1425-1431
   Web of Science | Medline

Author/Editor Response

Dr. Wintemute replies:

To the Editor: The comments of de Moore and Robertson emphasize that violence involving firearms results from long-standing personal and interpersonal difficulties and that existing programs will not identify many persons who are at risk for such violence. I agree with both points and will continue their discussion of the second.

In 1998, 63.3 percent of persons who were denied approval for the purchase of handguns were indicted or convicted felons; 13.3 percent had been convicted of misdemeanors involving domestic violence or were subject to restraining orders; 6.1 percent were fugitives. Only 0.7 percent of denials were based on mental illness or disability, and only 0.9 percent on drug addiction.1

Some 18 states have enacted broader criteria for denial of handgun purchases, which lead to 6.6 percent of all denials. California, for example, prohibits handgun purchases by persons who have been convicted of any misdemeanor on a list that includes most common violent misdemeanors. As compared with handgun purchasers with no criminal history, misdemeanants who buy handguns are much more likely to commit new gun-related or violent crimes.2 Prohibiting persons convicted of violent misdemeanors from purchasing firearms is widely supported; 75 percent of gun owners favor adding misdemeanors involving assault and battery to the list of criteria for denial, and 91 percent would prohibit handgun purchases by persons with misdemeanors involving the brandishing of a firearm.3 This approach works; prohibiting the purchase of handguns by persons with a record of violent misdemeanors reduces the risk that they will commit gun-associated or violent crimes.4

In addition, de Moore and Robertson mention the importance of a history of alcohol abuse and a history of other drug abuse as risk factors for suicide; both are risk factors for homicide as well. Federal law already prohibits the purchase of firearms by addicts and unlawful users of controlled substances. The law is rarely applied but should be vigorously enforced. Federal registries of persons registered as addicts or recently convicted of crimes involving the use of controlled substances should be established. A few states prohibit handgun purchases by persons who have been convicted of offenses involving the abuse of alcohol or other substances, but generally only if they have had multiple convictions. Again, such policies are widely supported; 59 percent of gun owners would prohibit gun purchases by persons who have been convicted of driving while drunk, and 89 percent would deny guns to those who have been convicted of possessing equipment for illegal drug use.3

Garen J. Wintemute, M.D., M.P.H.
University of California, Davis, Sacramento, CA 95817

4 References

1. 1

   Manson DA, Gilliard DK, Lauver G. Presale handgun checks: the Brady interim period: 1994-98. Washington, D.C.: Bureau of Justice Statistics, 1999. (NCJ 175034.)
   

2. 2

   Wintemute GJ, Drake CM, Beaumont JJ, Wright MA, Parham CA. Prior misdemeanor convictions as a risk factor for later violent and firearm-related criminal activity among authorized purchasers of handguns. JAMA 1998;280:2083-2087
   CrossRef | Web of Science | Medline

3. 3

   Teret SP, Webster DW, Vernick JS, et al. Support for new policies to regulate firearms: results of two national surveys. N Engl J Med 1998;339:813-818
   Full Text | Web of Science | Medline

4. 4

   Wintemute GJ, Wright MA, Drake CM, Beaumont JJ. Effectiveness of expanded criteria for denial of handgun purchase. In: Proceedings and abstracts of the 127th Annual Meeting of the American Public Health Association, Chicago, November 7–11, 1999. Washington, D.C.: American Public Health Association, 1999.
   

Citing Articles (2)

Citing Articles

1. 1

   Guy J. Ben Simon, Joseph Moisseiev, Nachum Rosen, Amir Alhalel. (2011) Gunshot Wound to the Eye and Orbit: A Descriptive Case Series and Literature Review. The Journal of Trauma: Injury, Infection, and Critical Care 71:3, 771-778
   CrossRef

2. 2

   S. Gault, C. Vialleton, B. Godey, B. Millet, F. Eudier. (2006) Tentatives de suicide par armes à feu avec destruction du visage : étude clinique et psychopathologique. Annales Médico-psychologiques, revue psychiatrique 164:4, 304-312
   CrossRef