Objectives
To estimate the number of lives saved from firearms suicide with expansions of gun restrictions based on mental health compared with the number who would be unnecessarily restricted.
Methods
Agent-based models simulated effects on suicide mortality resulting from 5-year ownership disqualifications in New York City for individuals with any psychiatric hospitalization and, more broadly, anyone receiving psychiatric treatment.
Results
Restrictions based on New York State Office of Mental Health–identified psychiatric hospitalizations reduced suicide among those hospitalized by 85.1% (95% credible interval = 36.5%, 100.0%). Disqualifications for anyone receiving psychiatric treatment reduced firearm suicide rates among those affected and in the population; however, 244 820 people were prohibited from firearm ownership who would not have died from firearm suicide even without the policy.
Conclusions
In this simulation, denying firearm access to individuals in psychiatric treatment reduces firearm suicide among those groups but largely will not affect population rates. Broad and unfeasible disqualification criteria would needlessly restrict millions at low risk, with potential consequences for civil rights, increased stigma, and discouraged help seeking.
In 2016, 44 965 individuals died by suicide in the United States.1 As many other leading causes of mortality have decreased in recent decades, the suicide rate has increased by more than 30% since 1999.2 Firearm-related suicide, in particular, along with the greater burden of firearm violence,3 remains a leading cause of death among those aged 10 to 54 years.4 The population-wide increase in firearm suicide deaths in the United States warrants a public health response. However, empirical data to evaluate different approaches to suicide prevention in the population are limited.
Mental illness is a key reason that many people attempt suicide,5,6 and access to a firearm is often the reason they die; guns are a highly lethal method of intentional self-injury.7,8 Thus, restricting access to firearms for people at risk for suicide, including many with serious mental illnesses, can save many lives.9–12 Gun prohibition linked specifically to involuntary psychiatric hospitalization is a longstanding federal policy. However, the fact that most gun suicide decedents have never been involuntarily hospitalized limits the effectiveness of point-of-sale prohibitions that are predicated on civil commitment alone. Gun restrictions that have been proposed or enacted have included people with records of any (voluntary or involuntary) psychiatric hospitalization,13–15 and, indeed, a few states have broader criteria, such as having a record of any psychiatric hospitalization (Connecticut) or even a record of any mental health treatment (Hawaii).
Enforcement of gun prohibitions based on mental health treatment history alone, without the legal safeguards of an adjudicatory process, is problematic from both a practical and civil rights standpoint. An estimated 44.7 million US adults have a diagnosable mental illness, and about 43% of these individuals are receiving treatment.16 The large majority of people treated for a mental illness in the community will neither die of suicide nor perpetrate violent acts. Moreover, restrictions can have unintended consequences; mental illness remains a highly stigmatized condition.17 Restrictions on firearm access linked to mental illness services utilization per se could discourage help seeking, especially among gun owners who believe that receiving mental health treatment will result in loss of their gun rights. Furthermore, associations between gun violence and mental illness more generally are complex and imbued with a problematic social and political history linked with race/ethnicity and class disparities.18 Guiding policy on firearm ownership to reduce suicide must balance efficacy with fairness, the protection of civil rights, and the goal of reducing stigma attached to mental illness.
In this study, we simulated randomized trials to estimate the hypothetical population-level effects of firearm ownership disqualification policies based on mental health records. We began with a prohibition predicated on any psychiatric hospitalization—a criterion that is broader than the current federal restriction linked to involuntary commitment but that still affects only a small proportion of the population. We then broadened the range of individuals who would be disqualified and examined the effect of gun prohibition based on any mental health treatment. Our model thus allowed us to explore both the benefits and social costs of such a broad restriction—to estimate its effectiveness, but also the extent to which it would preemptively restrict the rights of millions of law-abiding, nondangerous people. We examined the potential effect of firearm ownership disqualifications on overall population rates of firearm-related suicide, and also the effect on the targeted population of restricted individuals considered as a discrete group.
