Erin R. Morgan, MS; Anthony Gomez, BS; Frederick P. Rivara, MD, MPH; Ali Rowhani-Rahbar, MD, PhD
Acknowledgment: The authors thankful personnel at Public Health—Seattle & King County and the Washington State Department of Health for their contributions. They also thank the directors and leadership of the local and state public health departments for their dedicated support and encouragement.
Financial Support: State-added questions on firearms were funded by Clark County Public Health, Kitsap Public Health District, Public Health—Seattle & King County, Snohomish Health District, Spokane Regional Health District, Tacoma-Pierce County Health Department, and the Washington State Department of Health. This study was funded by Grandmothers Against Gun Violence. Data from the BRFSS are made available by the Washington State Department of Health, Center for Health Statistics, Behavioral Risk Factor Surveillance System and supported in part by the Centers for Disease Control and Prevention (cooperative agreements U58/SO000047-3 , U58/DP006066-01 , and NU58/DP006066-02-02 ).
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-3698.
Reproducible Research Statement: Study protocol: Available at www.doh.wa.gov/DataandStatisticalReports/DataSystems/BehavioralRiskFactorSurveillanceSystemBRFSS. Statistical code: Available from Ms. Morgan (e-mail, firstname.lastname@example.org). Data set: Available from https://fortress.wa.gov/doh/opinio/s?s=BRFSSDataOrderForm.
Table 1. Demographic Characteristics of Washington Residents Aged 65 Years or Older, by Household Firearm Ownership and Storage Practices*
Table 2. Prevalence of Suicide Risk Factors and Indicators of Memory Loss, by Household Firearm Ownership and Storage Practices*
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Salem Medical Center
April 19, 2019
"Safe" firearm storage
The authors evidence a bias in their definition of what constitutes "safe" gun storage. If an individual chooses to own a firearm for the reason of protection of themselves/their family and their property then storing a firearm unloaded and locked away renders it useless for that purpose. If someone chooses to own a firearm for that reason - which is perfectly valid and legal - then it is perjorative to them to suggest that they are not storing their firearms in as "safe" a manner as other firearm owners. This is what is explicitly stated in the article and it is inappropriate. The true definition of "safe" is a subjective one that depends on the individual firearm owner's situation and personal beliefs/choices.
Alan R. Ertle
Emeritus Enterprises, LLC
August 6, 2019
Household Firearm Ownership: Does it Make a Difference in the Elderly Suicide Rate?
I read the article by Morgan and colleagues with interest. Approximately 1% of Americans will die by suicide (1). Older men and women show the highest suicide rate in almost all countries, including those with very limited access to firearms such as Japan and China where the rate of suicide in the elderly is nearly three times that found in the United States (2,3). The authors cite the article by Angelmeyer and colleagues that concludes that the access to firearms is associated with risk for completed suicide and being the victim of homicide (4). However, this article was not specific to the elderly and thus makes it quite difficult to extrapolate to that population. The authors conclude, “…limiting access to lethal weapons for the older adult population represents an important avenue for suicide prevention.” Based on this study, it is impossible for the authors to conclude this. There is no evidence that limiting access to firearms would change the overall rate of suicide in the elderly in the US. Limited access to firearms might reduce the risk of suicide by firearms, but there is no evidence to support that the overall suicide rate would be reduced. This is supported by the higher rates of suicide in the elderly in countries with exceptionally limited access to firearms. With their logic, one should limit access to acetaminophen, ropes, automobiles, stairs, knives, bathtubs and a whole host of other potential suicide risks.
1. Centers for Disease Control and Prevention. [Accessed May 2014];FASTSTATS: Suicide and self-inflicted injury. Available at http://www.cdc.gov/nchs/fastats/suicide.htm.
2. World Health Organization 2017. [Accessed September 15, 2017]. Available from:http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/
3. Conwell Y, Thompson C. Suicidal behavior in elders. Psychiatr Clin North Am. 2008;31(2):333–356.[PMC free article] [PubMed] [Google Scholar]
4. 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.
Erin R. Morgan, MS, Anthony Gomez, BS, Frederick P. Rivara, MD, MPH, Ali Rowhani-Rahbar, MD, PhD
University of Washington
September 17, 2019
Dr. Ross has called to attention the assumptions on what constitutes safe storage. While preference for firearm storage techniques varies by owner circumstance, many professional medical and public health organizations have been consistent in messaging locked and unloaded storage as the safest practice.1 These positions are informed by decades of research beginning with the 1992 publication by Kellermann and colleagues which found associations between firearms in the home and suicide risk, which increased in magnitude when firearms were stored either unlocked or loaded.2 More recently, this question was assessed among adults over the age of 50, and storage was again found to be significantly associated with suicide death.3 Given the evidence supporting the association between locked and unloaded storage and reduced risk of suicide at all ages, and that several professional health organizations have published position papers supporting these methods, we believe that it is appropriate to consider firearms kept locked and unloaded as “safe” storage. Additionally, the availability of pushbutton locks on lockboxes can assure access to firearms within seconds, making such storage compatible with protection as the reason for owning a firearm.
Dr. Ertle raised the important issue of implications of safe storage specific to an older adult population and means substitution if firearms are not available. Firearm ownership and risk of suicide among those aged 50 and older has been studied and results are similar to those of other age groups.3 Increased risk of suicide in older adults across the world is significant but is not solely explained by the availability of firearms. It is important to note that the case fatality of firearm suicide attempts is far higher than suicide attempts by other means.4 While individuals making serious attempts to die by suicide may use other means, these means are less likely to be fatal. Some other countries with a lower prevalence of firearm ownership may have higher rates of suicide among older adults; however, it is important to consider that the difference in firearm ownership is not the only difference between the United States and Japan or China. Complex cultural differences in healthcare, socializing, views of the older adults, stigma surrounding mental health, and honor—among other differences—may also partially explain higher rates of suicide despite limited access to firearms.5
We recognize that limiting access to firearms alone is not sufficient to prevent all suicide deaths. Nonetheless, this is one potential opportunity for prevention.
1. Butkus R, Doherty R, Bornstein SS. Reducing Firearm Injuries and Deaths in the United States: A Position Paper From the American College of Physicians. Ann Intern Med. 2018;169(10):704. doi:10.7326/M18-1530
2. Kellermann A, Rivara F, Somes G, et al. Suicide in the home in relation to gun ownership. N Engl J Med. 1992;327(7):467-472.
3. Conwell Y, Duberstein P, Connor K, Eberly S, Cox C, Caine ED. Access to Firearms and Risk for Suicide in Middle-Aged and Older Adults. Am J Geriatr Psychiatry. 2002;10(4):407-416. doi:10.1097/00019442-200207000-00007
4. Shenassa ED, Catlin SN, Buka SL. Lethality of firearms relative to other suicide methods: a population based study. J Epidemiol Community Health. 2003;57(2):120-124. http://www.ncbi.nlm.nih.gov/pubmed/12540687.
5. Cheng ATA, Lee C-S. Suicide in Asia and the Far East. In: Hawton K, van Heeringen K, eds. The International Handbook of Suicide and Attempted Suicide. Chichester, UK: John Wiley & Sons, Ltd; 2000.
Morgan ER, Gomez A, Rivara FP, et al. Household Firearm Ownership and Storage, Suicide Risk Factors, and Memory Loss Among Older Adults: Results From a Statewide Survey. Ann Intern Med. 2019;171:220–222. [Epub ahead of print 16 April 2019]. doi: https://doi.org/10.7326/M18-3698
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Published: Ann Intern Med. 2019;171(3):220-222.
Published at www.annals.org on 16 April 2019
Geriatric Medicine, Neurology.
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