Firearm ownership and suicide: Has the time come to discuss uniformity of health and social assessments in aid of regulation? Reflection from a retrospective study on a forensic case series
Keywords:
Suicide, firearm, license, forensic medicine, regulation, health preventionAbstract
Background. Firearm-related deaths are an issue of ongoing public interest, from a health and economic perspective. Worldwide, firearm prevalence in suicides varies widely, depending on multiple factors including the availability of weapons in each country. Although several studies have shown that national laws about gun ownership, reducing legal access to guns, decrease the risk of suicide by firearm, the current situation clashes with widely differing legislations.
Study design. Retrospective study on a forensic case series.
Methods. Autopsy reports assessed at the Section of Legal Medicine of Milan (Italy) from January 2014 to December 2023 were retrospectively documented. Only firearm suicides were considered. For each case, a close analysis of the criminal offence reports has been performed to obtain information about the gender and age of the victim, as well as the legal possession of firearms, psychiatric disorders, alcohol, and illicit drug abuse.
Results. Among all the 1,164 suicides assessed at the Section of Legal Medicine of Milan over a 10-year-period, 101 cases (8.7%) were firearm-related. The male to female ratio was therefore about 13:1. No seasonal trends were observed. Most of the individuals owned the firearm license. Of the entire dataset, 35.6% suffered from psychiatric disorders, 4% of alcohol abuse and 2% of drug addiction. Among the owners of a firearm license, 42.3% had psychiatric disorders.
Conclusions. Knowledge about firearm suicide and its relation to firearm legal possession is limited and current preventive laws should be reconsidered. Present administrative and clinical examinations required to obtain a firearm license in Italy and in some European territories are dealt with. The evaluation of the firearm-related risk of abuse is an essential but complex procedure, which requires not only clinic-anamnestic data but also in-deep psychiatric information. There is a need to develop and reinvigorate a debate that currently presents very heterogeneous solutions, but which would probably benefit from a common vision of the prevention strategies that can be implemented and enacted for the benefit of the entire community
References
1. Fazel S, Runeson B. Suicide. N Engl J Med. 2020 Jan 16;382(3):266-274. doi: 10.1056/NEJMra1902944. Erratum in: N Engl J Med. 2020 Mar 12;382(11):1078.
2. Favril L, Yu R, Geddes JR, Fazel S. Individual-level risk factors for suicide mortality in the general population: an umbrella review. Lancet Public Health. 2023 Nov;8(11):e868-e877. doi: 10.1016/S2468-2667(23)00207-4.
3. Galante N, Gentile G, Tambuzzi S, Zoja R. Suicide pacts in the Milan district (Italy): A retrospective autopsy-based study with literature review. J Forensic Leg Med. 2022 Feb;86:102319. doi: 10.1016/j.jflm.2022.102319.
4. Vignali G, Blandino A, Rossetto I, Merzagora I. Intrafamiliar homicides: From 2006 to 2021 in the judicial district of Milan. J Forensic Leg Med. 2023 Jan;93:102453. doi: 10.1016/j.jflm.2022.102453.
5. Galante N, Blandino A, Disegna M, Franceschetti L, Casali MB. Intentional child and adolescent homicides in Milan (Italy): A 30-year interdisciplinary study. Leg Med (Tokyo). 2024 Mar 6;68:102433. doi: 10.1016/j.legalmed.2024.102433.
6. Junuzovic M, Rietz A, Jakobsson U, Midlöv P, Eriksson A. Firearm deaths in Sweden. Eur J Public Health. 2019 Apr 1;29(2):351-358. doi: 10.1093/eurpub/cky137.
7. Conner A, Azrael D, Miller M. Perceptions of Firearm Accessibility and Suicide Among US Adults Living in Households With Firearms. JAMA Netw Open. 2022 Oct 3;5(10):e2239278. doi: 10.1001/jamanetworkopen.2022.39278.
8. Junuzovic M. Firearm suicides in Sweden. J Forensic Leg Med. 2022 Oct;91:102403. doi: 10.1016/j.jflm.2022.102403.
9. Siegel M, Rothman EF. Firearm Ownership and Suicide Rates Among US Men and Women, 1981-2013. Am J Public Health. 2016 Jul;106(7):1316-22. doi: 10.2105/AJPH.2016.303182.
10. Conner KR, Zhong Y. State firearm laws and rates of suicide in men and women. Am J Prev Med. 2003 Nov;25(4):320-4. doi: 10.1016/s0749-3797(03)00212-5.
11. Dudley M, Cantor C, de Moore G. Jumping the gun: firearms and the mental health of Australians. Aust N Z J Psychiatry. 1996 Jun;30(3):370-81. doi: 10.3109/00048679609065001.
12. Gentile G, Clerici C, De Micheli A, Merzagora I, Palazzo E, Rancati A, et al. Analysis of 16 years of homicides and suicides involving the use of weapons recorded at the Milan Medicolegal Bureau. J Interpers Violence. 2013 Jan;28(2):386-415. doi: 10.1177/0886260512454715.
13. Reisch T, Steffen T, Habenstein A, Tschacher W. Change in suicide rates in Switzerland before and after firearm restriction resulting from the 2003 “Army XXI” reform. Am J Psychiatry. 2013 Sep;170(9):977-84. doi: 10.1176/appi.ajp.2013.12091256.
14. D.M. 28 Aprile 1998: Requisiti psicofisici minimi per il rilascio ed il rinnovo dell’autorizzazione al porto di fucile per uso di caccia e al porto d’armi per uso difesa personale. Available from: https://www.gazzettaufficiale.it/eli/id/1998/06/22/098A5324/sg [Last accessed: 2024 Jun 28].
15. D.lgs. 104 Agosto 2018. Attuazione della direttiva (UE) 2017/853 del Parlamento europeo e del Consiglio, del 17 maggio 2017, che modifica la direttiva 91/477/CEE del Consiglio, relativa al controllo dell’acquisizione e della detenzione di armi. (18G00127). Available from: https://www.gazzettaufficiale.it/eli/id/2018/09/08/18G00127/sg [Last accessed: 2024 Jun 28].
16. Ross CS, Gradus JL, Siegel MB, Alcorn T, Garverich S, Lincoln A. Distinct groups of firearm owners with differential risk for suicide in the United States: A latent class analysis. Prev Med. 2022 Nov;164:107185. doi: 10.1016/j.ypmed.2022.107185.
17. Kalesan B, Sampson LA, Zuo Y, Galea S. Sex and age modify the relationship between life circumstances and use of a firearm in suicide deaths across 17 U.S. states. J Affect Disord. 2018 Aug 15;236:105-111. doi: 10.1016/j.jad.2018.04.094.
18. Chao SD, Kastenberg ZJ, Madhavan S, Staudenmayer K. Impact of licensed federal firearm suppliers on firearm-related mortality. J Trauma Acute Care Surg. 2019 Jan;86(1):123-127. doi: 10.1097/TA.0000000000002067.
19. Boggs JM, Simon GE, Ahmedani BK, Peterson E, Hubley S, Beck A. The Association of Firearm Suicide With Mental Illness, Substance Use Conditions, and Previous Suicide Attempts. Ann Intern Med. 2017 Aug 15;167(4):287-288. doi: 10.7326/L17-0111.
20. Anestis MD, Selby EA, Butterworth SE. Rising longitudinal trajectories in suicide rates: The role of firearm suicide rates and firearm legislation. Prev Med. 2017 Jul;100:159-166. doi: 10.1016/j.ypmed.2017.04.032.
21. Opoliner A, Azrael D, Barber C, Fitzmaurice G, Miller M. Explaining geographic patterns of suicide in the US: the role of firearms and antidepressants. Inj Epidemiol. 2014 Dec;1(1):6. doi: 10.1186/2197-1714-1-6.
22. Miller M, Hemenway D. Guns and suicide in the United States. N Engl J Med. 2008 Sep 4;359(10):989-91. doi: 10.1056/NEJMp0805923.
23. Miller M, Azrael D, Hepburn L, Hemenway D, Lippmann SJ. The association between changes in household firearm ownership and rates of suicide in the United States, 1981-2002. Inj Prev. 2006 Jun;12(3):178-82. doi: 10.1136/ip.2005.010850.
24. Violanti JM, Steege A. Law enforcement worker suicide: an updated national assessment. Policing. 2021;44(1):18-31. doi:10.1108/PIJPSM-09-2019-0157.
25. Marzuk PM, Nock MK, Leon AC, Portera L, Tardiff K. Suicide among New York City police officers, 1977-1996. Am J Psychiatry. 2002 Dec;159(12):2069-71. doi: 10.1176/appi.ajp.159.12.2069.
26. Grassi C, Del Casale A, Cucè P, Kotzalidis GD, Pelliccione A, Marconi W, et al. Suicide among Italian police officers from 1995 to 2017. Riv Psichiatr. 2019 Jan-Feb;54(1):18-23. doi: 10.1708/3104.30936.
27. Costa T, Passos F, Queiros C. Suicides of Male Portuguese Police Officers - 10 years of National Data. Crisis. 2019 Sep;40(5):360-364. doi: 10.1027/0227-5910/a000570.
28. Kapusta ND, Etzersdorfer E, Krall C, Sonneck G. Firearm legislation reform in the European Union: impact on firearm availability, firearm suicide and homicide rates in Austria. Br J Psychiatry. 2007 Sep;191:253-7. doi: 10.1192/bjp.bp.106.032862.
29. Bauer A, Grinshpoon A, Garashonvinski A, Kalian M, Mester R. A comparison of firearms--related legislation on four continents. Med Law. 2003;22(1):105-11.
30. Ilic I, Zivanovic Macuzic I, Kocic S, Ilic M. Worldwide suicide mortality trends by firearm (1990-2019): A joinpoint regression analysis. PLoS One. 2022 May 25;17(5):e0267817. doi: 10.1371/journal.pone.0267817.
31. Killias M. International correlations between gun ownership and rates of homicide and suicide. CMAJ. 1993 May 15;148(10):1721-5.
32. Haw C, Sutton L, Simkin S, Gunnell D, Kapur N, Nowers M, Hawton K. Suicide by gunshot in the United Kingdom: a review of the literature. Med Sci Law. 2004 Oct;44(4):295-310. doi: 10.1258/rsmmsl.44.4.295.
33. Leenaars AA. Suicide by shooting and gun ownership (licenses) in Austria: Would gun restriction help? Wien Klin Wochenschr. 2006 Aug;118(15-16):439-41. doi: 10.1007/s00508-006-0639-5.
34. Etzersdorfer E, Kapusta ND, Sonneck G. Suicide by shooting is correlated to rate of gun licenses in Austrian counties. Wien Klin Wochenschr. 2006 Aug;118(15-16):464-8. doi: 10.1007/s00508-006-0643-9.
35. Beautrais AL, Fergusson DM, Horwood LJ. Firearms legislation and reductions in firearm-related suicide deaths in New Zealand. Aust N Z J Psychiatry. 2006 Mar;40(3):253-9. doi: 10.1080/j.1440-1614.2006.01782.x.
36. Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, et al. Suicide prevention strategies: a systematic review. JAMA. 2005 Oct 26;294(16):2064-74. doi: 10.1001/jama.294.16.2064.
37. Birner P. Suicide by shooting is correlated to rate of gun licenses in Austrian counties. Wien Klin Wochenschr. 2007;119(3-4):136; author reply 136-8. doi: 10.1007/s00508-007-0766-7.
38. Stulz N, Hepp U, Kupferschmid S, Raible-Destan N, Zwahlen M. Trends in suicide methods in Switzerland from 1969 to 2018: an observational study. Swiss Med Wkly. 2022 Dec 10;152:40007. doi: 10.57187/smw.2022.40007.
39. https://www.servicepublic.fr/particuliers/vosdroits/N287#:~:text=Les%20règles%20d%27achat%2C%20de,C%20est%20soumise%20à%20déclaration [Last accessed: 2024 Jun 28].
40. https://www.dw.com/en/gun-control-and-firearms-possession-in-germany/a-52450664 [Last accessed: 2024 Jun 28].
41. https://www.boe.es/buscar/pdf/1993/BOE-A-1993-6202-consolidado.pdf [Last accessed: 2024 Jun 28].
42. https://polisen.se/en/laws-and-regulations/firearms/weapon-licence/ [Last accessed: 2024 Jun 28].
43. https://www.ch.ch/en/safety-and-justice/owning-a-weapon-in-switzerland [Last accessed: 2024 Jun 28].
44. https://www.gov.uk/government/collections/firearms [Last accessed: 2024 Jun 28].
45. Merzagora I, Travaini G, Battistini A, Pleuteri L. Murder-suicide in the province of Milan, Italy: criminological analysis of cases 1990-2009. Med Sci Law. 2011 Apr;51(2):87-92. doi: 10.1258/msl.2010.010086.
46. Travaini G, Caruso P, Cornelli R, Merzagora I, Margherita M, Battistini A. Murder-suicides in Milan: case history from 1990 to 2018. Criminological and medico-legal considerations. Med Leg J. 2022 Jun 12:258172221075072. doi: 10.1177/00258172221075072.
47. Clerici CA, Veneroni L, Invernizzi R. La valutazione dell’idoneità psichica alla detenzione e al porto d’armi o allo svolgimento di servizi armati: revisione della letteratura e analisi critica dell’attuale situazione italiana. In: Atti Congresso Nazionale A.I.P., sezione di Psicologia Clinica, Cagliari 23 – 24 settembre 2005. Ortacesu: Nuove Grafiche Puddu; 2005: 491-493.
48. Shenassa E, Catlin S, Buka S. Gun availability, psychopathology, and risk of death from suicide attempt by gun. Ann Epidemiol. 2000 Oct 1;10(7):482. doi: 10.1016/s1047-2797-(00)00166-6.
49. Consiglio di Stato, III sezione, Sentenza 4403/2019.
50. Rilascio certificato medico di idoneità psicofisica per il rilascio/rinnovo della patente automobilistica o nautica. Available from: https://www.salute.gov.it/portale/moduliServizi/dettaglioSchedaModuliServizi.jsp?lingua=italiano&label=servizionline&idMat=SMAF&idAmb=PAT&idSrv=C1&flag=P [Last accessed: 2024 Jun 28].
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