Coronavirus Disease 2019 (COVID-19) and Firearms in the United States: Will an Epidemic of Suicide Follow?
Authors: Rebekah Mannix, Lois K. Lee, Eric W. Fleegler
Journal: Annals of Internal Medicine (2020)

Ideas and Opinions22 April 2020Coronavirus Disease 2019 (COVID-19) and Firearms in the United States: Will an Epidemic of Suicide Follow?FREERebekah Mannix, MD, MPH, Lois K. Lee, MD, MPH, and Eric W. Fleegler, MD, MPHRebekah Mannix, MD, MPHBoston Children's Hospital and Harvard Medical School, Boston, Massachusetts (R.M., L.K.L., E.W.F.)Search for more papers by this author, Lois K. Lee, MD, MPHBoston Children's Hospital and Harvard Medical School, Boston, Massachusetts (R.M., L.K.L., E.W.F.)Search for more papers by this author, and Eric W. Fleegler, MD, MPHBoston Children's Hospital and Harvard Medical School, Boston, Massachusetts (R.M., L.K.L., E.W.F.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-1678 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Since February 2020, as U.S. public health efforts have focused on containing the spread of coronavirus disease 2019 (COVID-19), gun sales in the country have skyrocketed. In March, more than 2.5 million firearms were sold, including 1.5 million handguns (1). In the best of times, increased gun ownership is associated with a heightened risk for firearm-related suicide (2). These are not the best of times. The United States faces an unprecedented combination of a public health and economic disaster. The physical distancing necessary to curb transmission of severe acute respiratory syndrome coronavirus 2 has disrupted social networks. Many people live in isolation, and the mental health of the population will likely suffer. Combined, these forces create a climate with the potential to increase firearm-related suicides.The firearm-related suicide crisis was mounting well before COVID-19. From 2006 to 2018, firearm-related suicide rates increased by more than 25% (3). In 2018 alone, there were 24 432 firearm-related suicides in the United States (3). Simultaneously, the number of firearm background checks increased from 10 036 933 in 2006 to 28 369 750 in 2019—an annual increase of 14% (4).However, something new is happening. The heightened gun sales in March 2020 represent an 85% increase compared with March 2019 (1). These are the highest firearm sales ever recorded in the United States. Persons who purchase handguns have a 22-fold higher rate of firearm-related suicide within the first year than those who did not purchase a handgun (5). Among men, for every 10–percentage point increase in household firearm ownership rates at the state level, there is an increase in firearm suicides of 3.1 per 100 000 persons (6). Decreased gun restrictions and increased access to firearms are associated with higher firearm-related suicide. On the individual level, the presence of a firearm in a home is associated with a 2- to 10-times greater risk for suicide than in a home without a firearm (7). This risk applies to all household members, not just the gun owner, and persists for years after the purchase of the firearms.The risks related to firearm ownership are well known and have not, by themselves, been sufficient to drive national firearm legislation. What is new is the economic and social tsunami caused by COVID-19. This combination of factors could unleash a wave of suicide that is disastrously enabled by the unfettered and growing exposure to household firearms.We know that natural disasters can have profound effects on mental health. A substantial proportion of persons exposed to a natural disaster will have psychological distress and develop mental health disorders. The likelihood of adverse mental health outcomes is augmented in the setting of economic stress. Unemployment alone is likely responsible for thousands of suicides each year. After the 2008 economic crisis, the relative risk for suicide associated with unemployment was elevated approximately 20% to 30% in 53 European countries and the United States, particularly among men and in countries with higher levels of job loss (8). As of 16 April 2020, more than 22 million Americans applied for unemployment insurance in just 4 weeks. This pandemic will clearly have lasting economic repercussions.Physical distancing, the primary public health intervention to limit the spread of COVID-19, also has the potential to worsen social isolation, a known risk factor for depression and suicide. The effects of short-term physical distancing have not been well studied, but social isolation can increase the risk for various health problems, including heart disease, depression, and dementia, which themselves could trigger suicidal behavior.We are therefore a society now primed for a suicide epidemic triggered by COVID-19. However, this is a predictable and preventable second wave. When all mechanisms are considered, most of those who attempt suicide do not die. The major preventable exception to this is firearm-related suicide, in which the fatality rate is more than 40 times that of drug poisoning, the most common suicide method (9).The time to act is now. Both population and individual approaches are needed to reduce the risk for suicide in the coming months. Federal and state programs targeting economic relief could have widespread influence on suicide rates. Advancing social connection should be a local and national public health priority. However, perhaps most important is thoughtfully limiting access to firearms, the most lethal means of self-harm, to those most at risk. Prior efforts at lethal means reduction to decrease suicides have shown success, including bridge barriers, removing carbon monoxide from domestic gas, and decreasing access to organophosphate pesticides. What is the best way to reduce firearm access among high-risk persons?State- and federal-level policies are needed. Only 16 states have effective firearm storage legislation. Federal buyback programs could provide an appropriate means for people to dispose of guns and offer much-needed economic incentives to do so. “Smart guns,” which restrict use through biometrics, should be made available for sale in the United States. Federal funding of firearm research is needed. Such funding has essentially been banned since 1996, during which time 800 000 firearm deaths have occurred (3). The recent modest allotment of federal firearm research funding is just a small start for researchers to investigate how to make firearm technology safer, keep people safer with their firearms, and improve firearm safety in society overall.However, policy changes alone will likely not suffice and are probably not imminent. At the patient level, clinicians are uniquely poised to identify and mitigate risk for firearm-related suicide (10). A discussion of access to lethal means, specifically firearms, and how to decrease risk, specifically removing the firearm from the home or, at a minimum, unloading and locking the firearm, is essential for patients with signs or symptoms or known histories of depression and other mental health disorders, substance use disorders, or dementia (3). Clinician-level counseling and distribution of safety devices (for example, trigger locks or lock boxes) can significantly increase safer firearm storage.The United States should take policy and clinical action to avoid a potential epidemic of firearm-related suicide in the wake of the COVID-19 pandemic.References1. Brauer J. U.S. firearms sales: March 2020 unit sales show anticipated covid-19-related boom. Accessed at http://smallarmsanalytics.com/v1/pr/2020-04-01.pdf on 4 April 2020. Google Scholar2. Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members. A systematic review and meta-analysis. Ann Intern Med. 2014;160:101-10. [PMID: 24592495] LinkGoogle Scholar3. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). Accessed at www.cdc.gov/injury/wisqars/fatal.html on 4 April 2020. Google Scholar4. Federal Bureau of Investigation. NICS firearm background checks: month/year. Accessed at www.fbi.gov/file-repository/nics_firearm_checks_-_month_year.pdf/view on 4 April 2020. Google Scholar5. Grassel KM, Wintemute GJ, Wright MA, et al. Association between handgun purchase and mortality from firearm injury. Inj Prev. 2003;9:48-52. [PMID: 12642559] CrossrefMedlineGoogle Scholar6. Siegel M, Rothman EF. Firearm ownership and suicide rates among US men and women, 1981-2013. Am J Public Health. 2016;106:1316-22. [PMID: 27196643] doi:10.2105/AJPH.2016.303182 CrossrefMedlineGoogle Scholar7. Dahlberg LL, Ikeda RM, Kresnow MJ. Guns in the home and risk of a violent death in the home: findings from a national study. Am J Epidemiol. 2004;160:929-36. [PMID: 15522849] CrossrefMedlineGoogle Scholar8. Chang SS, Stuckler D, Yip P, et al. Impact of 2008 global economic crisis on suicide: time trend study in 54 countries. BMJ. 2013;347:f5239. [PMID: 24046155] doi:10.1136/bmj.f5239 CrossrefMedlineGoogle Scholar9. Conner A, Azrael D, Miller M. Suicide case-fatality rates in the United States, 2007 to 2014. A nationwide population-based study. Ann Intern Med. 2019;171:885-895 [PMID: 31791066] doi:10. LinkGoogle Scholar10. Pallin R, Spitzer SA, Ranney ML, et al. Preventing firearm-related death and injury. Ann Intern Med. 2019;170:ITC81-ITC96. [PMID: 31158880]. doi:10.7326/AITC201906040 LinkGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Jonathan BernsteinSpecialty center13 May 2020 Suicides We have not seen an increase though I agree I would expect it - it may be because more people are home and the increase will happen soon after- we are also seeing less murders Author, Article, and Disclosure InformationAuthors: Rebekah Mannix, MD, MPH; Lois K. Lee, MD, MPH; Eric W. Fleegler, MD, MPHAffiliations: Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts (R.M., L.K.L., E.W.F.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-1678.Corresponding Author: Eric W. Fleegler, MD, MPH, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115; e-mail, eric.fleegler@childrens.harvard.edu.Current Author Addresses: Drs. Mannix, Lee, and Fleegler: Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115.Author Contributions: Conception and design: R. Mannix, E.W. Fleegler.Analysis and interpretation of the data: R. Mannix, L.K. Lee, E.W. Fleegler.Drafting of the article: R. Mannix, L.K. Lee, E.W. Fleegler.Critical revision of the article for important intellectual content: R. Mannix, L.K. Lee, E.W. Fleegler.Final approval of the article: R. Mannix, L.K. Lee, E.W. Fleegler.Administrative, technical, or logistic support: R. Mannix, E.W. Fleegler.Collection and assembly of data: R. Mannix, E.W. Fleegler.This article was published at Annals.org on 22 April 2020. 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Mental health and COVID-19: Self-inflicted and interpersonal violence amid a pandemic 4 August 2020Volume 173, Issue 3 Page: 228-229 Keywords COVID-19 Fire safety Firearm injuries Health economics Legislation Natural disasters Prevention, policy, and public health Psychiatry and mental health Research funding Suicide ePublished: 22 April 2020 Issue Published: 4 August 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...