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Chan School of Public Health

HARVARD PUBLIC HEALTH

MAGAZINE OF THE HARVARD T.H. CHAN SCHOOL OF PUBLIC HEALTH

Guns & Suicide

The Hidden Toll

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There’s a gas station maybe a five-minute drive away from us, and the gas station
sells guns. I didn’t realize places like that existed. Ryan just walked in and bought
a handgun. We had gotten into an argument—which we hardly ever did—and he
left. The next morning, the police knocked on my door. A construction crew had
found him dead in his car at an abandoned railroad station.

Emily Frazier, 27, widow of Ryan Frazier, who shot himself with a
semiautomatic in 2008

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Special report by Madeline Drexler, Editor, Harvard Public Health

I
n the national debate over gun violence—a debate stoked by mass murders such as last

December’s tragedy in a Newtown, Connecticut, elementary school—a glaring fact gets

obscured: Far more people kill themselves with a rearm each year than are murdered with

one. In 2010 in the U.S., 19,392 people committed suicide with guns, compared with 11,078 who

were killed by others. According to Matthew Miller, associate director of the Harvard Injury

Control Research Center (HICRC) at Harvard School of Public Health, “If every life is important,

and if you’re trying to save people from dying by gun re, then you can’t ignore nearly two-

thirds of the people who are dying.” Suicide is the 10th-leading cause of death in the U.S.; in

2010, 38,364 people killed themselves. In more than half of these cases, they used rearms.

Indeed, more people in this country kill themselves with guns than with all other intentional

means combined, including hanging, poisoning or overdose, jumping, or cutting. Though guns

are not the most common method by which people attempt suicide, they are the most lethal.

About 85 percent of suicide attempts with a rearm end in death. (Drug overdose, the most

widely used method in suicide attempts, is fatal in less than 3 percent of cases.) Moreover, guns

are an irreversible solution to what is often a passing crisis. Suicidal individuals who take pills

or inhale car exhaust or use razors have time to reconsider their actions or summon help. With

a rearm, once the trigger is pulled, there’s no turning back.

Not “Why?” but “How?”

When we think of suicide, we usually think of a desperate act capping years of torment.

According to the National Institute of Mental Health, complex and deep-rooted problems—

such as depression and other mental disorders, drug and alcohol abuse, family violence, and a

family history of suicide—often shadow victims. Suicide among males is four times higher than

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among females. In adults, separation or divorce raises the risk of suicide attempts. In young

people, physical or sexual abuse and disruptive behavior increase vulnerability.

The harrowing fact of suicide demands a story: “Why?” But from a

Cut it however
public health perspective, an equally illuminating question is “How?”
you want: In Intent matters, but so does method, because the method by which one

places where attempts suicide has a great deal to do with whether one lives or dies.

What makes guns the most common mode of suicide in this country?
exposure to
The answer: They are both lethal and accessible. About one in three
guns is higher,
American households contains a gun. The price of this easy access is
more people high. Gun owners and their families are much more likely to kill

die of suicide. themselves than are non-gun-owners. A 2008 study by Miller and

David Hemenway, HICRC director and author of the book Private Guns,
Deborah Azrael,
associate director Public Health, found that rates of rearm suicides in states with the
of the Harvard highest rates of gun ownership are 3.7 times higher for men and 7.9
Youth Violence
times higher for women, compared with states with the lowest gun
Prevention Center
ownership—though the rates of non- rearm suicides are about the

same. A gun in the home raises the suicide risk for everyone: gun

owner, spouse and children alike.

This stark connection holds true even when other factors are taken

into account. “It was a reasonable hypothesis to think that the type of

person who chooses to own a gun is di erent from the type of person who chooses not to.

Maybe there’s a ‘go-it-alone’ attitude that leads to less help seeking. Or maybe gun owners are

more likely to live in rural areas, and rural locales are associated with greater suicidality,”

explains Catherine Barber, director of HICRC’s Means Matter campaign, a suicide prevention

e ort that focuses on the ways people attempt to take their own lives. “But when we compared

people in gun-owning households to people not in gun-owning households, there was no

di erence in terms of rates of mental illness or in terms of the proportion saying that they had

seriously considered suicide,” Barber says. “Actually, among gun owners, a smaller proportion

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say that they had attempted suicide. So it’s not that gun owners are more suicidal. It’s that

they’re more likely to die in the event that they become suicidal, because they are using a gun.”

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He was struggling with

nightmares.” 
Emily Frazier’s 21-year-old husband, Ryan Frazier, shot himself with a
semiautomatic in November 2008, soon after bringing a lawsuit against a priest who
had molested him during his teenage years. Emily, pregnant at the time with their
second child, is now the single mother of a 5-year-old son and a 3-year-old
daughter. She works in human resources. The priest was convicted in 2007 and
sentenced to 30 days in jail.
Ryan and I met in high school and married right out of high school. He was friendly,
genuinely cared about everybody. He was one of the top ve salespeople in the country for
Verizon. He had a business card collection that I still have, it’s ve or six inches thick. People
would write down their number and they would want to meet up with him again, because he
was so kind. He was very young, handling a lot of responsibilities, working really hard, with
the sleep deprivation of having an infant. And he had struggled with nightmares since the
incident with the priest. Ryan had never used a gun before. The police report said he had red
test shots out the window of the car. After he died, I walked into the gas station where he had
bought the gun, and the owner was there. I asked him about the process for selling a gun and
if they ever screened people for mental illness. Then I said, “My husband bought a gun here
and shot himself.” The owner said just a couple of words. I couldn’t read his emotion. I don’t
know if he was uninterested or shocked. He didn’t say he was sorry.

While gun-suicide rates are higher in rural states, which have proportionally more gun owners,

the gun-suicide link plays out in urban areas, too. “In the early 1990s, the dramatic rise in

young black male suicides was in lock step with the homicide epidemic of those years,” says

HSPH’s Deborah Azrael, associate director of the Harvard Youth Violence Prevention Center.
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“Young black male suicide rates approached those of young white males—though black suicide

rates had always been much lower than white suicide rates. It was entirely attributable to an

increase in suicide by rearms.” Put simply, the fatal link applies across the board. “It’s true of

men, it’s true of women, it’s true of kids. It’s true of blacks, it’s true of whites,” says Azrael.

“Cut it however you want: In places where exposure to guns is higher, more people die of

suicide.”

Impulsive Acts

The scienti c study of suicide has partly been an

e ort to erase myths. Perhaps the biggest

fallacy is that suicides are typically long-

planned deeds. While this can be true—people

who attempt suicide often face a cascade of

problems—empirical evidence suggests that

they act in a moment of brief but heightened

vulnerability.

“One of the things that

The public
got me interested in
health launching the Means

message is Matter campaign was that I had been reading through thousands of

thumbnail sketches of suicide deaths, to see if a reporting system we

neither anti-
were testing was catching the feel for the case,” says Barber. “I started
gun nor pro-
noticing that, jeez, this death happened the same day that the kid was
gun. It’s pro- arguing with his parents, or that the young man had just broken up

data. with his girlfriend, or that the middle-aged guy had gotten word that

the divorce papers had come through. That reactivity surprised me,
Matthew Miller,
associate director because I’d always pictured suicide as being a painful, deliberative
of the Harvard process, something that was getting worse and worse, escalating until

nally you’ve got it all planned out and you do it. It hadn’t occurred to
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Injury Control me that it could be a cop arguing with his wife, and in the midst of the
Research Center
argument, pulling out his gun and killing himself.” This impulsivity

was underscored in a 2001 study in Houston of people ages 13 to 34

who had survived a near-lethal suicide attempt. Asked how much time

had passed between when they decided to take their lives and when

they actually made the attempt, a startling 24 percent said less than 5

minutes; 48 percent said less than 20 minutes; 70 percent said less

than one hour; and 86 percent said less than eight hours. The episodic

nature of suicidal feelings is also borne out in the aftermath: 9 out of 10 people who attempt

suicide and survive do not go on to die by suicide later. As Miller puts it, “If you save a life in the

short run, you likely save a life in the long run.”

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I couldn’t tell people that

my father had died of
suicide.”
Kristyn Bernier is a detective in Portsmouth, New Hampshire. Her father, Bruce
Rogers, a dentist in Connecticut, shot himself in August 2003, at the age of 63.
He had suffered for years from undiagnosed depression. Rogers used an antique
hunting rifle that had been in the family. Late one evening, after several rounds
of drinks, he surreptitiously took cartridges from an open box of ammunition on a
neighbor’s refrigerator.
My father had a great sense of humor. He had a thriving dental practice. Volunteered all over
the place, he was on every board. In his spare time, he re nished furniture. He made baskets,
caned chairs. Those beautiful chairs–I have a couple of them. But he was lonely. Things
changed around him, we all changed, and he didn’t. I am a master at dealing with crisis. I’m
a hostage negotiator. I was an EMT for 25 years. I handle child sexual assault cases. I handle
felony domestics. I interview predators day in and day out. I have seen the most horrible
things people do to each other. But I missed this crisis in my own family. I couldn’t tell
people that my father had died of suicide. I came up with creative ways to answer the
question of how he had died. “He died suddenly”–that was my answer. Even in my line of
work, suicide is a stigma. And if people aren’t willing to talk about suicide after it happens,
how do you expect them to talk about the risks beforehand?

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Lethal Environments

A central tenet of public health is that environment shapes individual behavior. In the realm of

suicide, this truth has played out dramatically in recent history. When widely used lethal means

are made less available or less deadly, suicide rates by that method decline, as do suicide rates

overall. In Sri Lanka, for example, where pesticides are the leading suicide method, the suicide

rate fell by half between 1995 and 2005, after the most highly human-toxic pesticides were

restricted. Similarly, in the United Kingdom before the 1950s, domestic gas derived from coal

contained 10 to 20 percent carbon monoxide, and poisoning by gas inhalation was the leading

means of suicide. A source of natural gas virtually free of carbon monoxide was introduced in

1958; over time, as carbon monoxide in gas decreased, so did the number of suicides overall—

driven by a drop in carbon monoxide suicides, even as other methods increased somewhat.

Changing the means by which people try to kill themselves doesn’t necessarily ease the suicidal

impulse or even the rate of attempts. But it does save lives by reducing the deadliness of those

attempts.

Dearth of Data

Though these basic facts are known, there is a striking dearth of research on guns and suicide.

In the U.S., government o cials don’t even have current data on where household gun

ownership rates are higher or lower. The only survey large enough to produce state-level

estimates of gun ownership was conducted by the federal Behavioral Risk Factor Surveillance

System, the world’s largest ongoing telephone health survey. The survey asked questions about

gun ownership in 2001, 2002 and, for the last time, in 2004. It was HICRC investigators who

analyzed this state-level data to show that suicide rates run in tandem with gun ownership

rates.

Today, the U.S. Centers for Disease Control and Prevention’s National Violent Death Reporting

System, which collects data from police and coroners’ reports and death certi cates on every

suicide and homicide, covers only 18 states. Compare this with the National Highway Tra c

Safety Administration’s Fatality Analysis Reporting System, which amasses extensive details
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within 30 days of every fatal car crash on

public roads, from the time and location

of the accident to weather conditions to

the role of alcohol and drugs. Partly as a

result of this bureaucratic diligence, the

fatality rate from car crashes has dropped

by about a third over the last two

decades. Could the same dedication bring

down suicides? Matthew Miller thinks it

can. “Better data is a good place to start. KENT DAYTON / HSPH

That way, discussions are grounded in

Harvard School of Public Health researchers
facts rather than distorted by ideology. It
have conducted many of the key national studies
can only help foster social-norm- linking gun access and suicide. Left to right:

shifting conversations similar to those Matthew Miller, associate director of the

Harvard Injury Control Research Center (HICRC);
that took place around cigarette
Deborah Azrael, associate director of the
smoking, safety belt use and driving Harvard Youth Violence Prevention Center; and
drunk,” he says. “I’d like physicians to Catherine Barber, director of HICRC’s Means
Matter campaign.
feel it’s their responsibility to tell people

about the risks. There’s no reason that you should have a conversation about a bike helmet or a

seat belt, but not rearms.” But change also takes time. “With public health, when you don’t

have the one-size- ts-all solution, you chip away at the problem,” says Barber. Preventing

suicides will likely require many approaches, from education and media campaigns to skilled

treatment and community support. Ultimately, the goal is to transcend politics—which is why

those who have lost loved ones to gun suicide should have the last word:

Ryan is my baby. I remember once telling him, “If anything

happens to you, I would cease to exist.” And that’s what it feels

like. It’s a pain like no other. I would encourage open conversation

—actually talking about it. Preventing just one person from going

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through what I went through and will go through for the rest of

my life—that would be enough for me.

Wendy Tapp, mother of 19-year-old Ryan Tapp, who shot himself with a handgun in 2011

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A club I never wanted
to join.”
Janyce Demers is a school lunch worker in Hooksett, New Hampshire. Her 23-year-old
son, Zachary Demers, killed himself with a firearm in 2008–hours after a first
drunken driving arrest. Zachary may have been afraid of losing his commercial
driver’s license, a great source of pride and accomplishment.
Being a suicide survivor is a club I never wanted to join. But it wasn’t my choice. Zach’s death
was a shock to all of us. He was happy-go-lucky, loved his family, loved his sisters, loved his
nephews and nieces. But he thought he was in over his head nancially. And he was still
living at home–that was a bother to him. To have even considered suicide, he must have
been so low, just beyond anything. I went back and looked through all his school papers.
What stood out in his teachers’ comments was his impulsiveness. Being impulsive, you
sometimes make rash decisions, spur-of-the-moment, and they don’t always turn out for
the best. There were guns in our home. My husband has hunting ri es. My daughter and my
son-in-law have guns for target practice. Zach had purchased his own rearm for hunting
and target practice. That being said, I am not a gun lover–I really don’t care for them. But
I’m also not anti-gun. I believe there are people who can be trusted with guns for the right
purposes. Today, if I notice anyone in trouble, I don’t step back and assume it’s none of my
business. I approach them and say, “Hey, are you thinking of doing this?” I’ll ask them
directly, “Do you have a gun?” I’ve experienced it and I’m no longer afraid to ask. People
need to know that help is available?

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Starting a
Conversation
To foster open discussion about the consequences of gun ownership, public health

researchers want to know much more about the lure of guns. Why do people own guns in

the rst place? How do they perceive the risks and bene ts? Is the gun mainly for self-

protection? Hunting? Target practice? Picking o wild animals that eat crops? And are

there other ways to answer those needs that don’t involve guns? They’d also like to know

why people just got rid of their last gun or acquired their rst. What drives decisions at

these in ection points? Is it divorce from a gun-owning spouse? Moving to a city, where

guns are less prevalent? The fact that young grandchildren are starting to visit? And

researchers are curious about the beliefs and experiences of non-gun-owners living in a

home with a gun. Studies have shown that women are’t always aware that their partners

or children are keeping guns, suggesting that these wives and mothers would disapprove

if they did know.

The blunt question that community

gatekeepers should ask clients or
friends who seem troubled: Is there a
gun in your home?

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Community “Gatekeepers”

Psychiatrists, psychologists and social workers have begun trainings on how to talk with

suicidal patients and their families about reducing access to rearms at home.

Unfortunately, people contemplating gun suicide are not always in treatment and often

don’t display clues in advance–not even to themselves. According to Catherine Barber,

director of the Harvard Injury Control Research Center’s Means Matter campaign, “They

may think: ‘It’s not my assessment of the world that’s the problem, it’s the world. I’m

headed back to jail, my girlfriend’s broken up with me, I’ve got no hope for the future.’”

Even when deep despair prompts people to seek help, theirclinicians often fail to ask

about guns or feel uncomfortable broaching the topic, in part because they lack suicide

prevention training. All of which suggests that informal contacts, outside the familiar

channels of mental health care, may serve as a stronger safety net. In public health lingo,

these potentially lifesaving friends and colleagues are known as “gatekeepers.” They

include teachers, school psychologists, truant o cers, sports coaches, pediatricians,

emergency department doctors, defense attorneys, court-mandated batterers’

counselors, social workers, rehab clinicians, employee-assistance sta , divorce

attorneys, marriage counselors, and clergy. According to Barber, “It’s those people who

need to get the message, because that’s where suicidal people intersect with the system.”

The blunt question these gatekeepers should ask clients or friends who seem troubled: “Is

there a gun in your home?” Barber believes that most e orts to keep a rearm away from

a suicidal person should be based on conversation, not con scation. Though some

situations–such as with delusional individuals–may be too dangerous to allow guns to

remain nearby, in most cases an engaged and respectful approach is more e ective. “You

want to bring about safety through conversation,” she says. “Very rarely do you want to

take control away from a person at risk of suicide.”

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The
Gun Shop
Project
In April 2009, over a ve-day period, two young men and an older woman in New

Hampshire each bought handguns from Riley’s Sport Shop in Hooksett and within hours

committed suicide. The victims did not know each other. Soon, as often happens in a

small, rural state, word spread, as did the desire to prevent such a triple tragedy from

happening again. Thus began the Gun Shop Project, a novel collaboration, guided by the

New Hampshire Firearm Safety Coalition, of mental health and public health

practitioners, rearms dealers and gun rights advocates. HSPH injury researchers

Catherine Barber and Mary Vriniotis helped organize the project, interview gun shop

owners and develop educational materials.

To some, the notion of suicide

prevention groups nding

common cause with gun sellers

seems implausible. But to Barber, it

makes perfect public health sense.

“You’re trying to reach gun

owners,” she says. “Gun control

isn’t the way to go for suicide

prevention groups, because these

REUTERS
groups are made up of both gun

owners and non-gun-owners.

Even internally, they might not agree.” In many ways, the gun-friendly state of New

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Hampshire–where the Association of Chiefs of Police recently raised money for an annual

cadet training program by selling ra e tickets for 31 guns, including an assault ri e–is

the perfect proving ground for creative approaches to gun-suicide prevention. Each year,

the state sees about 20 homicides, but 150-200 suicides; about half of those suicides are

by gun. Riley’s sells thousands of guns each year. When he learned of the three suicides

committed back-to-back with rearms from his store, owner Ralph Demicco was

horri ed. “The suicide issue deeply impacts me,” Demicco says. “I’ve had friends who

have taken their lives. I’ve had wives of friends who have taken their lives. And as a

businessperson, having a customer do it–it’s just an ugly, ugly thing. I decided I must

become involved.” Demicco reviewed the store’s surveillance tapes of the soon-fatal

transactions, to see if the customers were giving away clues to their intent. They weren’t.

But Demicco recalled earlier instances when he had picked up such clues: a customer

asking for a very small amount of ammunition, or looking uneasy, or starting to cry after

being asked a few questions–and his tactful inquiries diverted them from their plans. Over

the past three years, the Gun Shop Project group produced instructional videos and

tipsheets for gun retailers. “Trust your instincts; you are under no obligation to sell a gun

to anyone,” says a handout from the New Hampshire Firearm Safety Coalition. Demicco

encourages all customers who are not familiar with rearms to get training before he will

sell them a gun–valuable from a prevention point of view, because it buys time during

which a crisis will often pass. Posters and brochures for customers discuss how to make

rearms inaccessible if a family member appears troubled. They also prominently display

the phone number for the National Suicide Prevention Lifeline (1-800-273-TALK). About

half of New Hampshire’s gun retailers are participating in the project, and the Maryland

Firearms Dealers Association will be adopting the model this year. The initiative even

earned plaudits in the magazine Combat Handguns. The next step, says Barber, is to

encourage suicide prevention groups to team up with other natural allies such as hunting

groups, shooting clubs and gun rights groups. “It’s important that gun owners and non-

gun-owners talk to one another,” she says. “The question can’t be, ‘What do you think of

gun control?’ because everybody’s going to be for or against. But when the question is,

‘How do we solve the problem of gun suicide?’ we can work out good ideas that everyone

can agree on.

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Politics
& Beyond
Gun violence is one of the most politically divisive issues in the United States–and this

contentiousness has played out in government funding of research. In 1993, a study supported

by the U.S. Centers for Disease Control and Prevention (CDC) found that, rather than conferring

protection, keeping a gun in the house raises the risk nearly threefold of being shot by a family

member or intimate acquaintance. Enraged by what it has called an “almost vicious sentiment

against personal rearms ownership,” the National Ri e Association in 1996 successfully

lobbied Congress to insert this restriction into the CDC budget: “None of the funds made

available … may be used to advocate or promote gun control.” It was a pointed prohibition that

went far beyond the rule that federal research money cannot be used for lobbying on any issue.

The restriction, which was interpreted broadly by CDC, served as a virtual ban on rearms

research. Since the mid-1990s, the agency’s gun safety research budget has dropped by 96

percent. In 2011, the NRA’s o cial website o ered a rationale for its e orts to sti e research:

“These junk science studies … are designed to provide ammunition for the gun control lobby by

advancing the false notion that legal gun ownership is a danger to the public health instead of

an inalienable right.”

Trusting the messenger

But according to Matthew Miller, associate director of the Harvard Injury Control Research

Center (HICRC), “The public health message is neither anti-gun nor pro-gun. It’s pro-data. A

public health approach doesn’t look so much to blame as to understand and prevent.”
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“Like older white men, people with mental

health problems, people with family

histories of suicide, etc., gun owners are

‘our’ people,” adds the HICRC’s Catherine

Barber, referring to groups with increased

suicide risk. “We can’t reach them with an

anti-gun agenda. That’s like sending an

anti-gay group to do a suicide prevention

campaign in the gay and lesbian

KEVIN LAMARQUE / REUTERS
community. If you don’t trust the

messenger, you don’t trust the message.”

The Newtown, Connecticut, massacre, in which the young gunman, Adam Lanza, ended his

own life after the elementary school rampage, opened another public health line of argument:

that preventing suicides may also prevent homicides, including the relatively tiny number of

mass murders. “Mass homicide is an outrageously hostile acting out,” says Miller, “and one

can only imagine that it is deeply connected with a hostility directed at oneself as well.” Yet for

Barber, the public health conversation around guns is actually trickier since Newtown, because

political positions have grown more entrenched. Toiling for years on the knotty problem of gun

suicide has changed her perspective on gun control. “I’m more aware of the cultural divide

between gun owners and non-gun-owners, especially when they become politicized and think

ill of one another,” she says. “Some gun owners think guns make their family safer. A lot of the

guys, they love the mechanism in guns–it’s the same as the love for ne woodworking tools.

There can also be cultural connections, where they learned to shoot from their dad or their

uncle. Gun owners and non-gun-owners are both caring, but they view the world di erently.”

Could new laws prevent gun suicide?

The current political debate swirls around universal background checks and assault weapons

bans and magazine limits–policies unlikely to have a measurable impact on suicide. Deborah

Azrael, associate director of the Harvard Youth Violence Prevention Center, is heartened by a

less-trumpeted 1999 Connecticut law, which provides a mechanism for people to contact police
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when they fear a gun will be used for harm.

Police and prosecutors may obtain

warrants to seize rearms from people who

appear to be an imminent danger to

themselves or others. The individual whose

guns are taken has the right to a hearing

within two weeks. “There have been

hundreds and hundreds of people who have

TIM SHAFFER / REUTERS
been motivated to call the police since the

law was put into e ect in the late 1990s,”

says Azrael. “And they’re not saying, ‘I think my husband is going to kill me.’ They’re saying, ‘I

think my husband is going to kill himself.’”

“The courage of our convictions”

Azrael worries that in the revived debate on gun violence, suicide will be eclipsed. She also

laments that public health researchers are often reluctant to spin out the implications of the

scienti c evidence about rearms, for fear of being accused of an anti-gun bias. “It’s a

constraint that most researchers don’t operate under. People who do research on lung cancer

are allowed to draw conclusions about smoking. The same with people who do research on

environmental exposure to PCBs, or on motor vehicle design issues, or on drug overdoses.

There’s no national organization pillorying them or actively seeking to defund them.” In other

words, the frank and open conversation about guns that Americans need to have among

themselves also applies to researchers who want to share their ndings with the public. As

Azrael sees it, “We need to have the courage of our convictions.”

Madeline Drexler is the editor of Harvard Public Health Banner photo: Jan Stromme /

gettyimages.com

View a map that shows every school shooting since Sandy Hook

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10/23/2019 Guns & Suicide | Harvard Public Health Magazine | Harvard T.H. Chan School of Public Health

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