Why it is time for a public health approach to preventing suicide

Matthew Miller, MD, MPH, ScDAssociate Director,

Harvard Injury Control Research Center

Background• GGB: Leading suicide

location worldwide• More than 1200 suicides

since 1937 – Approximately one suicide every 2-

3 weeks– 4 foot railing, no other barrier

• Not always the uncontested leader among sites worldwide

– the Eiffel Tower, St. Peter’s Basilica, the Sydney Harbor and Arroyo Seco Bridges, Mt. Mihara

Percent who think ALLJumpers would find another way to kill themselves if a foolproof anti-suicide barrier were put up

on the Golden Gate BridgeMultivariate Odds

Ratio (95% CI)

All respondents (n=2638)

Male (n=1310)

Female (n=1328)

Current Smoker (n=548)

Not a Current Smoker (n=2087)

Personally own a firearm (n=735)

Live in a household with guns but do not personally own any firearms (n=296)

Live in a household without firearms (n=1560)

Barriers to Suicide and Suicide Prevention: Public Opinion and the Golden Gate Bridge

Miller M, Azrael D, Hemenway D. Belief in the inevitability of suicide: results from a national survey. Suicide and Life Threatening Behavior. 2006. 36(1):1-11.

Simplistic model of some causes of fatal and non-fatal suicidal behaviour

GENETIC FACTORS

PERSONALITY FACTORS

Cultural meaning of suicide/ role

models/media influences

PSYCHIATRIC DISORDERS

Life Events/Crises

Aggression Impulsivity

Hopelessness

Method likely to be

lethal

Method unlikely to be

lethal

NON-FATAL ATTEMPT

SUICIDE

AVAILABILITY OF METHOD

SUICIDAL BEHAVIOUR

Modified from Keith Hawton, PhD

Causes of Violent Death, Worldwide

• ~ one million suicides annually worldwide– 16 per 100,000, or one

death every 40 seconds.

• Suicide is now among the three leading causes of death among those aged 15-44 years

Armed Conflict

20%

Suicide50%

Homicide30%

Source: WHO, Violence and Health, Report of the Secretariat, November 2001

How many SPH offer courses on suicide prevention?

Leading Causes of Death, US, 2002

2003 Deaths

Suicides 31,484 Firearm Suicides 16,907 (54%)

Homicides 17,732Firearm Homicide 11,920 (67%)

HICRC 2004 Firearms Survey

Households with Kids

Households without Kids

Firearm prevalence 39% 38%

In Households with Guns:% Unlocked•% Loaded•% Loaded & Unlocked

48% 22%5%

56% 31% 12%

Hepburn L, Miller M, Azrael D, Hemenway D. Firearm ownership in the US: findings a national survey. Preliminary findings

Non-fatal Self-Harm vs. Suicide, United States

Cut/pierce22%

Drown/Near-drown*0%

Fall1%

Firearm*1%

Poisoning75%

Inhalation/suffocation

1%

WISQARS Non-Fatal Injury Reports (2003 Data) seen in ER regardless of dispositionWISQARS Fatal Injury Reports (2003 Data)

Firearm55%

Poisoning18%

Suffocation21%

Cutting/piercing2%

Drowning1% Fall

2%

Suicide (n=31,484)Non-fatal Self-Harm (n=411,128)

Relationship of attempted suicide to completed suicide

Attempted Suicides

Completed Suicides

AB <10% of A

AB= 25%-30% of B

AB

Source: Maris R.W. (1981) Pathways to suicide: A survey of self-destructive behaviors.Reprinted in Maris, Berman, Silverman, eds. Comprehensive Textbook on Suicidology, 2000.

Suicide Attempts and Case Fatality Rate by Method Seven Northeast States, 1996-2000

All Methods Firearm Poisoning/Cutting/Piercing

Suffocation/Hanging

All Other Methods

Percent of suicide acts by methods

100% 5% 85% 5% 5%

0

0.2

0.4

0.6

0.8

1

Cas

e Fa

talit

y R

ate

CFR 0.13 0.91 0.03 0.74 0.15

All Methods Firearm Poisoning / Cutting /

Suffocation / Hanging

All Other Methods

Source: Miller, Azrael, Hemenway, Annals of Emer Med, 2004.

Guns used in suicide

Rifle or Shotgun

54%Handgun

46%

Youth17 and under

Adults18 and over

Rifle or Shotgun

40%Handgun

60%

The vast majority (~90%) of firearms used in suicides come from the victims home

From: Keith Hawton, PhD

SUICIDE RISK

A ACUTE RISK (only)

B ACUTE ON CHRONIC RISK

x yPeriod of extra

riskChronic risk

x yRisk periodNo risk

• Suicide acts are often impulsive

• Crises are often temporary

• 90% of survivors of near-lethal suicide attempts do not commit suicide thereafter

Means Restriction as a Suicide Prevention Strategy

SURVIVORS OF SELF-INFLICTED SHOOTING

• 33 survivors of self-inflicted firearm injuries

• Most common reason for shooting was interpersonal conflict with partner or family members (21 patients)

• Act almost always described as impulsive

• All used firearms available in household and availability was often reason given for choice of this method

(De Moore et al, 1994)

Impulsivity

ImpulsivityFactors associated with the medical severity of suicide attempts in youths and young adults (Swahn MH, Potter LB, 2001)

•25% of 153 survivors of near lethal suicide attempts acted within 5 minutes of the impulse to do so

•71% acted within one hour

Sri Lanka Pesticide Suicides (Eddleston, 2006 JCT)

•268 self-poisonings, 85% noted choice of poison dictated by what was readily at hand

•Little premeditation

On the bridge, Baldwin counted to ten and stayed frozen. He counted to ten again, then vaulted over. “I still see my hands coming off the railing,” he said. As he crossed the chord in flight, Baldwin recalls, “I instantly realized that everything in my life that I’d thought was unfixable was totally fixable—except for having just jumped.”

Tad Friend. Jumpers. The New Yorker (2003)

CRISIS | same-day• Did suicide occur within 24 hours of a

very recent crisis or precipitating event?– e.g. arrest, job loss, argument, relationship

break-up, legal trouble, police pursuit, bad report card

• Purpose is to identify suicides that may have an impulsive element

Crisis, same day

Victim was a 16 year-old boy who had been suspended from school for misbehavior. His mother grounded him and they got in a loud argument. He ran from the room, slammed the door, went to the basement and shot himself with his father’s rifle. No known mental health history.

CRISIS | % same day by age

6

13

2021

33

0-17 18-24 25-44 45-64 65+

Age group

%

2001 Data

N=1,671 CT, ME, UT, WI, Allegheny County, San Francisco County

Lifetime Risk of Suicide Among Five Populations of Psychiatric Patients

From: Bostwick: Am J Psychiatry, Volume 157(12).December 2000.1925-1932

Prognosis after attempted suicide

Prognosis after attempted suicide

Prognosis after attempted suicide

Does availability of methodaffect suicide rates?

THE COAL GAS STORY(Kreitman, 1976)

0

2

4

6

8

10

12

14

1955 1960 1965 1970 1974Year

Perc

ent C

OPercentage of CO in domestic gas, United Kingdom 1955-74

THE COAL GAS STORY (Kreitman, 1976)

0

2

4

6

8

10

12

14

55 57 59 61 63 65 67 69 71Year

Total

Non CO

CO

Sex-specific suicide rates by mode of death: England & Wales

0

2

4

6

8

10

12

14

55 57 59 61 63 65 67 69 71Year

Total

Non CO

CO

Males Females

Rat

e pe

r 10 0

,000

Ra t

e pe

r 10 0

,000

Source: Natl. Center for Health StatisticsAge-adjusted to 1940 U.S. population

0

2

46

8

10

1214

16

18

1933

1935

1945

1955

1965

1975

1985

1995

2001

0

10

20

30

40

50

60

Suicide Rate

% Adults in Householdswith Guns

Suicide Rates United States, 1933-2001

45

67

8

Sui

cide

Rat

e (p

er 1

00,0

00 p

opul

atio

n)

2530

3540

4550

3 Y

ear R

ollin

g Av

erag

e of

Hou

seho

ld G

un O

wne

rshi

p

1980 1985 1990 1995 2000

Year

3 Yr. Rolling Average Household Gun Ownership Non-Firearm Suicide Rate

Firearm Suicide Rate

Figure 2. Household gun ownership levels and rates of firearm and non-firearm suicide mortality:United States, 1981-2002

Miller M, Azrael D, Hepburn L, Hemenway D, Lippmann S. Injury Prevention. 2006. In Press.

% Decrease in

Firearm Suicide Rate

(95% Confidence

Interval)

% Decrease in

Non-Firearm Suicide Rate

(95% Confidence Interval)

% Decrease in

Overall Suicide Rate

(95% Confidence

Interval)

Total Population 4.2% (2.3% –6.1%) *** 0.3% (-1.4% – 2.3%) 2.5% (1.4% –3.6%) ***

Males 3.4% (2.8% –4.1%) *** 1.1% (-0.7% –2.9%) 2.3% (1.7% – 2.9%)***

Females 3.4% (1.9% – 4.9%) *** -0.5%(-1.9% – 1.9%) 1.0% (0.4% – 1.6)**

Children (0-19

years of age) 8.3% (6.1% –10.5%) *** -0.4.% (-2.9% –2.1%) 4.1% (2.3% –5.9%) ***

Miller M, Azrael D, Hepburn L, Hemenway D, Lippmann S. Injury Prevention. 2006.

Table 1. Longitudinal Association between Household Gun Ownership and Suicide Mortality: Percent Decrease in Mortality Rate for each 10% Decrease in Household Firearm Ownership Level (1981-2001), adjusted for age, unemployment, poverty, per capita alcohol consumption and region of the country

Why might declines occur?– Improved life circumstances– Improved mental health – Improved mental health treatment (SSRIS?)– Cohort characteristics– Changes in social norms– Coding changes– Changes in population (e.g. large influx of

immigrants with lower suicide rates; change in age distribution)

In most of these scenarios, we would expect to see attempts and completions by all methods going down.

12-month prevalence of suicide related behaviors, 15-54 year olds (National Co-morbidity Survey)

1990-1992 NCS

2001-2003NCS

P Value

Ideation 2.8% 3.3% 0.44

Gesture 0.3% 0.2% 0.24

Attempt 0.4% 0.6% 0.44

Kessler et al. JAMA. 2005;293:2487-2495

Rates of Household Firearm Ownership and Rates of Suicide, Firearm Suicide and Non-Firearm Suicide across 7 North East States, 1996-2000

Percent of Households

with Firearms Suicides per

100000 Firearm Suicides

per 100000 Non-Firearm Suicides per

100000 Vermont 42% 12.3 8.0 4.3 Maine 41% 13.3 7.8 5.5 New Hampshire 30% 11.7 6.2 5.5 Connecticut 17% 8.5 3.3 5.2 Rhode Island 13% 8.3 3.0 5.3 Massachusetts 12% 7.5 2.1 5.4 New Jersey 12% 7.1 2.3 4.8 All 7 States 17% 8.2 3.1 5.1

Miller M, Azrael D, Hemenway D. Firearms and Suicide in the Northeast. Journal of Trauma. 2004; 57:626-632

Suicide attempt rate with non-firearm methods did not significantly correlate with firearm prevalence

Firearms and Suicide across the 50 US States,1999-2002

Dependent Variable• Firearm and non-firearm suicide mortality rates Independent Variables• Household Firearm Prevalence (BRFSS 2002)• Alcohol and illicit substance abuse and dependence-• Serious mental illness • Unemployment • Poverty and urbanization

Miller M, Lippmann S, Azrael D, Hemenway D. Journal of Trauma. 2006. In Press.

Suicides by Age Group: The 15 U.S. States with the Highest vs. the 6 U.S. States with the Lowest Average Household Gun Ownership* (2000-2002)

High-Gun States(Total Pop., 2000-2002:

115 Million)

Low-Gun States(Total Pop., 2000-2002:

118 Million)

Mortality Rate Ratio

(High Gun : Low Gun)

47% of Households have firearms

15% of Households have firearms

35-64 year olds

5-19 Year OldsFirearm Suicide 654 121 5.5Non-Firearm Suicide 417 339 1.3Total Suicide 1071 460 2.4

Firearm Suicide 4674 1316 3.6Non-Firearm Suicide 2775 2992 1.0Total Suicide 7449 4308 1.8

Miller, Azrael, Hemenway. Journal of Trauma. 2006. In Press

Correlation Coefficients: rates of suicide, firearm suicide, non-firearm suicide, lifetime major depression, lifetime suicidal thoughts and firearm ownership, US Census regions

Suicide Rate Firearm suicide rate

Non-firearm suicide rate

Major depression

Suicidal thoughts

Household Handgun prevalence

0.59 0.83 -0.57 -0.10 -0.01

Hemenway D, Miller M. Association of rates of household handgunownership, lifetime major depression, and serious suicidal thoughts with rates of suicide across US census regions. Injury Prevention 2002; 8:313-316

Psychiatric disorder prevalence estimates by census region, 1991-92 (National Co-morbidity Study, n=48,000). Lifetime major depression (n=8098) and ever seriously considered suicide (n=5877) were reported by 17% and 13% of respondents nationally. Mean household firearm and handgun ownership rates come from the General Social Surveys.

Controlled for per capita alcohol consumption, unemployment, college education from NCS

Personally Own Firearms (n=762)

Households with Firearms (n=1075)

No Firearms (n=1639)

2.8% 2.9% 4.9%

Seriously Considered Suicidein Past 5 Years

HICRC National RDD Survey, 2004

Miller et al. 2006.

Case Control: Brent et al

Five overlapping studies of adolescents in Western PA (no one study with more than 70 suicides)

Results common to all studies:–Firearms in the home strongly associated with risk of suicide

(OR=2 to 5)

Brent et al

Case Control: Kellermann et al

Suicide in the HOMEAll agesLarge study (803 suicides)

•Results:–Firearms in the home strongly associated with risk of suicide–The association is strongest for adolescents/young adults and for individuals without a known psychiatric history–Risk greater if gun stored loaded or unlocked–Risk is elevated for all members of the household

Kelermann, NEJM, 1992

Case Control: Cummings et al RQ: Is the purchase of handgun from licensed dealer associated with suicide, risk vary with time since purchase, risk extend to family members?

•Results:–Suicides more likely than controls to live in household in which a family member had purchased a handgun (RR=1.9).

•RR=2.0 if an individual himself purchased the gun and 1.5 if the handgun was purchased by another family member•Risk greatest within first year, persists even after 5 years

Cummings et al, AJPH, 1997

Grossman et al, JAMA, February 9, 2005.

Storage Practices and Suicide Risk, 5-19 year olds

No. (%)

Firearm Storage Practice Cases(N=106)

Controls(N=480)

Adjusted Odds Ratio (95% CI)

Gun unloaded 66% 91% 0.30 (0.16-0.56)

Gun locked 32% 58% 0.27 (0.17-0.45)

Ammunition locked 24% 48% 0.39 (0.23-0.66)

Risk of Suicide in the Home in Relation to Various Patterns of Gun Ownership

Variable Adjusted Odds Ratio

95% Confidence Interval

Type of guns in the homeOne or more handguns 5.8 3.1 – 4.7Long guns only 3.0 1.4 – 6.5No guns in the home 1.0 --

Loaded gunsAny gun kept loaded 9.2 4.1 – 20.1 All guns kept unloaded 3.3 1.7 – 6.1No guns in the home 1.0 --

Locked gunsAny guns kept unlocked 5.6 3.1 – 10.4All guns kept locked up 2.4 1.0 – 5.7No guns in the home 1.0 --

Source: Kellerman et al. 1992. NEJM

Parents of 106 Adolescents with Major Depression

Follow up 2 yrs

Not counseled

27% removed guns from home

Told about the increase risk of suicide conveyed by

guns in the home

73% retained guns in home

Follow up 2 yrs

17% acquired guns

Asked if firearms in the home

27% Yes 73% No

Brent et al. 2000: JAACAP

Do Interventions work?

Survey of ED Nurses in Illinois (n=527)

Experience PercentageRecent experience with suicidal adolescents

80% (n = 407)

Ever received means restriction training

24%(n = 122)

Provided means restriction education to parents

28%(n = 136)

Worked in units where means restriction is standard practice

18%(n = 89)

Grossman et al, 2003: JAPNA

Are we trying hard enough?

Poison center chart reviewF/U call to caretakers, 6-24 months

after suicide attempt by adolescent

Are we delivering the right message?

Potentially lethal means available in the home at the time of the

attempt

• 75% prescription medication• 86% OTC medications• 2% street drugs

– 95% had some medication available at time of SA

• 25% firearms

At follow-up

~10% reported that injury prevention education was given about restricting access medication– 86% locked up medications (vs. 32% of those w/o IP education)

No one (0%) reported being told that firearms in the home increase the risk of suicide

76% of the adults were not worried about thepossibility of a repeat suicide attempt by their adolescent

Active OppositionIn early 2006, two separate but virtually identical

bills were introduced in the Virginia and West Virginia legislatures

– Each bill would have prohibited a physician from asking a patient if he or she owned firearms for the purpose of counseling that patient about ways to reduce risks associated with firearms

– Penalties for violation of the bills included revocation of a physician's license to practice

Counseling about firearms: proposed legislation is a threat to physicians and their patients. Vernick JS, Teret SP, Smith GA, Webster DW. Pediatrics 2006; 118(5):2168-72

Passive Opposition

Percent who think ALLJumpers would find another way to kill themselves if a foolproof anti-suicide barrier were put up

on the Golden Gate BridgeMultivariate Odds

Ratio (95% CI)

All respondents (n=2638) 34% NA

Male (n=1310) 37%*** 1.05 (0.86, 1.28)

Female (n=1328) 31% Reference

Current Smoker (n=548) 43%*** 1.55 (1.25, 1.93)***

Not a Current Smoker (n=2087) 32% Reference

Personally own a firearm (n=735) 48%*** 2.10 (1.70,2.59)***

Live in a household with guns but do not personally own any firearms (n=296) 36%*** 1.36 (1.02,1.81)*

Live in a household without firearms (n=1560) 26% Reference

Barriers to Suicide and Suicide Prevention: Public Opinion and the Golden Gate Bridge

An additional 40% thought that most jumpers would have found another way to complete suicide

Miller M, Azrael D, Hemenway D. Belief in the inevitability of suicide: results from a national survey. Suicide and Life Threatening Behavior. 2006. 36(1):1-11.

Conclusions

• Suicide is preventable • Means Matter• Interventions can change behavior• Message infrequently delivered/ received• Active and Passive Opposition• The Deadly Breach• Opportunity for success

Questions?

Discordance Between Parent and Child Responses to Questions about Household

Firearms

Know Location HandledAll children 39% 22%Household firearms All locked 46% 17% Some unlocked 30% 29%Parent Report Discussed gun safety w child 40% 21% Never discussed gun safety w child 39% 29%

Baxley and Miller, 2006: APAM

21 Grounds for Revocation of a Medical License in Virginia

1. False statements, fraud, deceit2. Substance abuse3. Intentionally or neglig. harming a patient4. Mental or physical incapacity5. Conviction for moral turpitude6-21. Other egregious conduct

Vernick, Teret, Smith, Webster. Under review by Pediatrics.

VA HB 1531 Sought to Add #22

22. “Oral or written inquiry to a patient concerning the possession, ownership, or storage of firearms, where such inquiry has no relationship to the practice of the healing arts or the medical condition of the patient, and is for the purpose of gathering statistics or to justify patient counseling, unless such inquiry is the subject of a request, or related to a medical complaint, made by the patient.”

HB 1531: What Happened Next

• Jan 20: Bill introduced• Feb 13: Passed VA State Assembly, 88-11• Feb 14-22: Lobbying by NRA and AAP• Feb 23: Defeated in VA Senate Comm., 9-

6• Feb 24: Virtually identical bill introduced in

West Virginia• Mar 19: WV session closes with no action

Implications of the Bills

• Medical Malpractice• The First Amendment

Dr. Timothy Wheeler: “This was not a badshowing for a first try at a boundary violationbill”.

Case Control: Cornwell et al All Suicides, 65 years and olderLarge study (86 cases and 86 community controls matched on age, sex, county of residence)

•Results: –Presence of a firearm in the home was associated with increased risk for suicide, even after controlling for psychiatric illness.–Elevated risk was accounted for by access to handguns rather than long guns–RR more pronounced in men than women–Storing the weapon loaded and unlocked were independent predictors of suicide

Cornwell, Am J Geriatric Psychiatry, 2002

Case Control: Wiebe

All Suicides drawn from the 1993 National Mortality Followback SurveyLarge study (1,959 cases and 13,535 controls from National health interview Survey matched on age, sex, race)

•Results: –Presence of a firearm in the home was associated with increased risk for suicide: 66% of suicides lived in households with guns vs. 37% of controls–OR=3.4 (3.1, 3.9)–Elevated risk was accounted for by access to handguns rather than long guns

Wiebe, AEM,41(6): 771-82, 2003

Guns used in suicide • Among 35 gun suicide victims aged 17 and under, the

owner of the gun was documented in 26 cases.• In 92% of cases (24/26), the gun came from the family.

Owner # % Parent 21 80.8Other family 1 3.8Self, received from parent 2 7.7Self, source unknown 2 7.7Total 26 100.0

92%

*Among adults as well, firearms used in suicide are predominantly household guns

Rates of Household Firearm Ownership and Rates of Suicide, Firearm Suicide and Non-Firearm Suicide across 7 North East States, 1996-2000

Percent of Households

with Firearms Suicides per

100000 Firearm Suicides

per 100000 Non-Firearm Suicides per

100000 Vermont 42% 12.3 8.0 4.3 Maine 41% 13.3 7.8 5.5 New Hampshire 30% 11.7 6.2 5.5 Connecticut 17% 8.5 3.3 5.2 Rhode Island 13% 8.3 3.0 5.3 Massachusetts 12% 7.5 2.1 5.4 New Jersey 12% 7.1 2.3 4.8 All 7 States 17% 8.2 3.1 5.1

Miller M, Azrael D, Hemenway D. Firearms and Suicide in the Northeast. Journal of Trauma. 2004; 57:626-632

Rates of Self-harm (per 100,000), 7 Northeast States, 1996-2000, by State and Method (per 100,000 population) across 7 North East States, listed in order of firearm prevalence, highest to lowest

Suicide Attempt Rate All Methods

Suicide Attempt Rate

Firearm

Suicide Attempt Rate

Poisoning/ Cutting/ Piercing

Suicide Attempt Rate Suffocation/

Hanging

Suicide Attempt Rate All Other

Methods

Vermont 77 9 63 2 3 Maine 80 9 66 3 3 New Hampshire 78 7 65 3 3 Connecticut 67 4 57 3 2 Rhode Island 76 3 65 4 3 Massachusetts 64 2 55 4 3 New Jersey 55 3 48 3 2 Percent of suicide attempts by method

100% 5% 85% 5% 5%

Miller M, Azrael D, Hemenway D. Firearms and Suicide in the Northeast. Journal of Trauma. 2004; 57:626-632

Baxley & Miller (2006)

Suicide Rates by Method

0 2 4 6 8 10 12 14 16 18

Suicide Deaths/100,000

Denmark

Australia

New Zealand

Canada

Scotland

Norw ay

US

The Netherlands

Eng & Wales

Israel

Firearm Poisoning Suffocation All Other

Source: Lois A. Fingerhut, MA, Centers for disease Control and Prevention, Unpublished

Tested Positive for Alcohol (83% tested)

5%

35%

<18 yrs Adults

Youth alcohol use

The Association between Changes in Household Firearm Ownership and Rates of Suicide in the United States,

1981-2002

Dependent Variable• Firearm and non-firearm suicide mortality rates from WISQARS, 4 Census regions, 1981-

2002

Independent Variables• Percentage of individuals living in households with firearms (gun prevalence) – General

Social Survey (GSS)• Age• Per capita alcohol consumption - National Institute on Alcohol Abuse and Alcoholism• Unemployment – Bureau of Labor Statistics• Poverty and urbanization – Census Current Population Survey

Analysis• GEE modeling to account for serial auto-correlation• Regional fixed effects controlled for cross sectional, time invariant differences among the

four census regions.

The association between changes in household firearm ownership and rates of suicide in the United States, 1981–2002. .M Miller, D Azrael, L Hepburn, D Hemenway, S J Lippmann. Injury Prevention 2006;12:178–182.

Rates of Self-harm (per 100,000), 7 Northeast States, 1996-2000, by State and Method (per 100,000 population) across 7 North East States, listed in order of firearm prevalence, highest to lowest

Suicide Attempt Rate All Methods

Suicide Attempt Rate

Firearm

Suicide Attempt Rate

Poisoning/ Cutting/ Piercing

Suicide Attempt Rate Suffocation/

Hanging

Suicide Attempt Rate All Other

Methods

Vermont 77 9 63 2 3 Maine 80 9 66 3 3 New Hampshire 78 7 65 3 3 Connecticut 67 4 57 3 2 Rhode Island 76 3 65 4 3 Massachusetts 64 2 55 4 3 New Jersey 55 3 48 3 2 Percent of suicide attempts by method

100% 5% 85% 5% 5%

Miller M, Azrael D, Hemenway D. Firearms and Suicide in the Northeast. Journal of Trauma. 2004; 57:626-632