Restricting access to lethal means of suicide is one of the most effective approaches to suicide prevention, as supported by successive systematic reviews of the international literature. Means restriction can operate as a population-based approach to suicide prevention or as part of individual’s personal suicide risk management strategy, designed to hamper opportunities to attempt suicide. It is based on the observation that even though suicide is the consequence of multiple complex factors, the urge to act on one’s suicidal ideation is usually not long-lasting, which means that an individual’s access to highly lethal means has a critical influence on their likelihood of death. Approaches to means restriction include limiting the toxicity and availability of specific medications to prevent self-poisoning, and architectural interventions to prevent deaths by jumping.
The reach of any means restriction intervention relates to how common a suicide method is in a specific region. Hanging, pesticide suicide, and firearm suicide are the three methods dominating country-specific suicide patterns, with jumping from a height and self-poisoning also being prevalent in specific countries. Pesticide suicide is common in Asian countries and in Latin America, whereas firearm suicide predominates in several countries in the Americas and some European countries, particularly where firearm ownership is common in private households. Limiting access to a specific means of suicide may be a calculated approach or it may arise indirectly from other influences on availability. For example, serendipitous means restriction interventions include the reduction in toxicity of gas used for domestic ovens when British energy supplies were switched from coal gas to natural gas for economic reasons, following which the number of suicides by gas poisoning fell dramatically. In contrast, deliberate legislative changes include the 1998 restriction on paracetamol pack sizes in Britain, following which there was a significant reduction in suicides by that method.
Firearms restriction, control and safeguarding measures are an important means of suicide prevention because firearms are a highly lethal means of suicide. In a US epidemiological study, firearm suicide attempts accounted for 5% of all attempts, yet an estimated 91% of all suicide attempts involving firearms were fatal. In another US sample only 12% of people who died by firearm suicide had a prior history of suicide attempt, compared with 29% for those who died by other means of suicide, with both studies suggesting its greater lethality at first attempt. There is a clear association between firearm ownership and firearm suicide rates at both the individual and regional level. One approach to reducing firearm suicide has been the regulation of firearm ownership at the national or state level. Where such legislation has been introduced, for example in Canada in 1978 and Australia in 1996, a reduction in firearm suicides has been observed, although this may be explained by other factors. However, US studies have consistently found a heightened suicide risk in households that own firearms compared to those that do not, regardless of factors such as psychopathology gender and age. Although the households with and without firearms do not differ in the proportions of those with suicidal ideation or plans, the likelihood of any suicidal thoughts or plans to involve firearms is seven times greater in households with firearms than those without.
This report represents a rare opportunity to study firearms control as a serendipitous suicide prevention strategy in a country where firearms ownership was uncommon prior to a period of armed conflict: the Republic of Croatia. This is a country that tends to be under-represented in the suicide literature, despite being in an area of comparatively high suicide rates following a period of political and socioeconomic disruption. We report here the changes in suicide rates that occurred after a legislative change concerning firearms that was not directly intended to reduce suicide by this means, but nevertheless was effective in doing so.
