One in Six Firearm-Related Homicides and Suicides in Women Found To Be Related to Pregnancy

About one in six intentional firearm-related deaths in women of childbearing age occur during or shortly after pregnancy, a study in the American Journal of Preventive Medicine has found.

Naima T. Joseph, M.D., M.P.H., of Boston Medical Center and colleagues analyzed data from the Centers for Disease Control and Prevention’s National Violent Death Reporting System from 2008 to 2019. Women aged 15 to 44 years who died by suicide or homicide involving a firearm were included. The researchers defined pregnancy-associated deaths as deaths that occurred during pregnancy or within one year of childbirth.

Over the study period, there were 4,204 firearm-related homicides and deaths by suicide: 2,098 were homicides, of which 22% were associated with pregnancy; and 2,106 were deaths by suicide, of which 11% were associated with pregnancy. Women and girls who died by pregnancy-associated homicide had an average age of 22.2 years, and 54.8% were Black; the average age of those who died by pregnancy-associated suicide was 28.5 years, and 80.5% were White.

The researchers also found the following notable differences where relevant circumstances were known:

• 83.5% of pregnancy-associated suicides occurred in a metropolitan county versus 72.8% of suicides unrelated to pregnancy.
• 61.6% of pregnancy-associated homicides were related to ongoing conflict with or violence by a current or former partner versus 51.9% among homicides unrelated to pregnancy.
• 4.2% of pregnancy-associated deaths by suicide occurred in women who experienced intimate partner violence within a month of death versus 1.3% of deaths by suicide that were unrelated to pregnancy.

“The findings are concerning and indicate that enhanced strategies supporting mental health treatment, effective interventions addressing interpersonal violence, and strategic public health interventions addressing firearm safety are urgently needed to prevent needless pregnancy-associated violent deaths,” Joseph and colleagues wrote. “There is concern that the current national political landscape will serve to worsen the risks of intimate partner violence for pregnant individuals both through restriction of access to abortions and limiting states’ abilities to restrict firearms.”

For related information, see the Psychiatric News article “Gun Violence Is an Underrecognized Social Determinant of Health.”

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Study Highlights Relationship Between Alcohol, Suicide, and Firearms

Alcohol intoxication is associated with an increased risk of suicide death by firearms compared with other methods, especially among males and among young and middle-aged females, a study in the American Journal of Preventive Medicine suggests.

“Understanding the nuances of the relationship between alcohol and firearm-involved suicides—the method of suicide that makes up the greatest proportion of suicides in the U.S.—allows for a better understanding of how a prevention initiative targeting alcohol (e.g., alcohol taxation), for example, would impact suicide in the U.S.,” wrote Shannon Lange, Ph.D., M.P.H., of the Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, in Toronto and colleagues.

The researchers examined data from the National Violent Death Reporting System for 34,972 females and 113,851 males who died by suicide from 2003 to 2020. The researchers divided the individuals according to age at time of death: young, aged 18 to 34 years; middle-aged, aged 36 to 64 years; and older, aged 65 years or older. The individuals’ blood alcohol content at the time of death was determined via toxicology testing. The researchers defined alcohol intoxication as having a blood alcohol content of at least 0.08 g/dL, which corresponds to approximately four drinks for females and five drinks for males within two hours.

Overall, males were more likely to be intoxicated at the time of death than females, and people in the young and middle-aged groups were more likely to be intoxicated at the time of death than those in the older group. Males were more likely to use a firearm than females, and older males had the highest proportion of death by suicide using a firearm.

Young and middle-aged females who were intoxicated at the time of death had a 31% and 34% greater risk of using a firearm compared with their non-intoxicated peers, respectively. Young, middle-aged, and older intoxicated males had a 28%, 17%, and 4% increased risk of using a firearm compared with their non-intoxicated peers, respectively.

“In light of the current findings, there is a clear need for prevention efforts to address the alcohol-firearm-suicide relationship,” Langue and colleagues wrote. They added that such efforts could include the following:

• Laws that prohibit firearm possession for individuals with alcohol use disorder or who are being treated for alcohol-related reasons.
• Screening and brief interventions for alcohol use of all individuals who present in the health care system with suicidal thoughts or for a suicide attempt and connecting these individuals with resources for treatment for substance use.
• The enactment of safe firearm storage policies and mandatory waiting periods following a firearm purchase.
• Minimum unit pricing on alcohol.

“Given that a firearm is the most lethal means of suicide, alcohol control policies targeting excessive alcohol consumption may stem the tide of firearm suicides in the U.S.,” the authors wrote.

For related information, see the Psychiatric Services article “Preventing Suicide Through Better Firearm Safety Policy in the United States.”

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Experts Offer Tips on Talking About Firearms With Adolescents at Risk of Suicide

Mental health professionals who work with adolescents should ask about access to lethal means, including firearms, when assessing their patients who are at risk of suicide, according to the authors of a clinical perspectives piece in the Journal of the American Academy of Child & Adolescent Psychiatry.

“Many adolescent suicide attempts are impulsive; completed suicides may be prevented if access to firearms is limited during periods of crisis,” wrote Apurva Bhatt, M.D., of the University of California, Davis, and colleagues. “However, many clinicians do not talk about firearms with patients even when clinically relevant. This may be due to assumptions that adolescents do not have access to firearms, or to lack of comfort with this topic.”

The authors offered several tips to help child and adolescent mental health professionals approach the topic of firearms with their patients:

Be informed and respectful. Conversations about reducing the risk of firearm suicide are more effective if they are approached with knowledge and respect for the various reasons for ownership.

Establish context, assess risk, and ask about firearms. This should be a nonjudgmental conversation wherein the mental health professional asks about whether the adolescent has access to firearms not only at home, but at the homes of friends or family members where the adolescent spends time.

Provide tailored recommendations. Once an adolescent has been identified as at risk for suicide, mental health professionals should discuss their concerns with the adolescent’s caregiver and work collaboratively to reduce the youth’s access to firearms. They can use a harm reduction approach with shared decision-making and emphasize that the goal is to keep the person at risk as safe as possible.

Follow up with continued discussions. Follow-up discussions can foster a trusting relationship about the health and safety of all family members.

“By being informed and respectful, establishing context, and providing tailored recommendations for each clinical situation, clinicians can provide this important suicide prevention intervention in their clinical practice,” the authors concluded.

For related information, see the Psychiatric Services article “Promoting Firearm Safety as a Suicide Prevention Strategy Within Health Care Systems: Challenges and Recommendations.”

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Suicide Risk Increases Immediately After Gun Purchase

A study published in the New England Journal of Medicine expands on past research on the association between access to guns and suicide, finding that handgun ownership is associated with an elevated risk of suicide by firearm, particularly immediately after the gun is acquired.

Since the COVID-19 pandemic began, gun sales have sharply increased, an accompanying commentary pointed out. In March, Americans bought nearly two million guns, marking the second-highest monthly total since 1998, when the Federal Bureau of Investigation (FBI) began publishing such data.

“How will the current surge of gun purchases affect firearm-related violence?” wrote Chana A. Sacks, M.D., M.P.H., and Stephen J. Bartels, M.D., in their commentary. “With an additional 2 million guns now in households across the country at a time of widespread unemployment, social isolation, and acute national stress that is unprecedented in our lifetime, we urgently need to find out.”

Lead author David M. Studdert, LL.B., Sc.D., of the Stanford Law School and School of Medicine and colleagues tracked firearm ownership and mortality over 12 years (2004-2016) among 26.3 million adults in California. They used the California Statewide Voter Registration Database to form the cohort, as the database updates its information on registered voters in the state every year.

The researchers then used the California Department of Justice’s Dealer Record of Sale for details on which cohort members acquired handguns and when. Additionally, the California Death Statistical Master Files provided records of all deaths reported during the study period.

In total, 676,425 members of the cohort acquired one or more handguns during the study period, and 17,894 died of suicide, of which 6,691 were suicides by firearm. “Handgun owners had lower rates of all-cause mortality than nonowners but substantially higher rates of suicide,” the authors wrote.

The rate of suicide by firearm among handgun owners peaked immediately after the gun purchase (within 30 days) but remained relatively higher 12 years later. Fifty-two percent of all suicides by firearm among handgun owners occurred more than a year after acquisition of a gun.

Women accounted for only 16% of all suicides by firearm, but the rate of suicide by any method among female handgun owners was seven times higher compared with female nonowners. The corresponding suicide rate among male handgun owners was three times as high as that of nonowners.

The findings have several implications for clinical care and suicide prevention, wrote Sacks and Bartels in their commentary. Assessments of suicide risk should include questions about recent gun ownership and access to firearms, for example, and women, as well as men, should be questioned about gun ownership, they wrote.

“Fifty-nine people were killed in the mass shooting in Las Vegas in 2017, the deadliest in U.S. history. Approximately the same number die each day in the United States from suicide by firearm,” Studdert and colleagues concluded. “Many of these deaths are preventable.”

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Time for Action: APA to Hold Town Hall on Structural Racism

APA President Jeffrey Geller, M.D., M.P.H., will lead a webinar town hall on Monday, June 15, at 8 p.m. EDT with distinguished panelists on the topic of structural racism experienced by Black Americans. The panelists include Danielle Hairston, M.D.; Thea James, M.D.; Ayana Jordan, M.D., Ph.D.; and Walter E. Wilson Jr., M.D., M.H.A. The discussion will be followed by a Q&A session with APA members about the way forward for our organization.

Learn More and Register Now