Guns And Suicide

Transcript for: 
Guns And Suicide

MS. DIANE REHM

10:06:55
Thanks for joining us. I'm Diane Rehm. About two-thirds of all gun-related deaths in this country are suicides. Among suicide victims, a gunshot wound is the most likely cause of death. Joining me to talk about guns and suicide, Dr. Jana Martin, clinical psychologist, Dr. Alan Newman, a forensic psychiatrist at Georgetown University Medical Center, and, joining us from a studio at Harvard University, Dr. Matthew Miller, associate professor of health policy and injury prevention at the Harvard School of Public Health.

MS. DIANE REHM

10:07:36
I invite you to be part of the conversation. Do join us, 800-433-8850. Send us your email to drshow@wamu.org. Follow us on Facebook or Twitter. And good morning to all of you.

DR. JANA MARTIN

10:07:56
Good morning.

DR. MATTHEW MILLER

10:07:57
Good morning.

REHM

10:07:58
Good to have you all with us. Dr. Newman, let me start with you. Talk about the suicide rates and the trends in this country, especially as they relate to gunshots.

DR. ALAN NEWMAN

10:08:13
Absolutely. Suicide is a huge problem in this country. It is actually the 10th leading cause of death. Approximately 38,000 people a year commit suicide, and the overall rate in the United States is about 11 per every 100,000. There's certain populations that are at much higher risks. So even though it's the 10th leading cause of death in adults, it's actually the third leading cause of death in young people and adult -- young adults and adolescents.

DR. ALAN NEWMAN

10:08:42
There are certain times in life where the risk of suicide is much greater. So there's a peak of suicide risk between the ages of 40 and 59, and then it goes down a little bit. But then there's another very concerning peak around age 75 and older where the risk of suicide is about 50 percent greater than the risk to the rest of the population.

REHM

10:09:04
And to what extent is that percentage by gun?

NEWMAN

10:09:10
Over 50 percent. The numbers vary some, but in the United States, the total number of suicides by firearms is greater than the other causes combined.

REHM

10:09:21
You spoke about age groups. What about among young people as far as gunshots are concerned?

NEWMAN

10:09:31
Well, particularly among adolescents, you know, it's the third leading cause of death, although one of the three is homicides. And so guns are involved heavily in two of the three leading causes of death.

REHM

10:09:47
Dr. Martin.

MARTIN

10:09:48
Yes. In 2009, the statistics were that there were 4,600 suicidal deaths among youth, and 44.5 percent of those were by firearms.

REHM

10:09:59
And were the firearms usually small guns?

MARTIN

10:10:06
Yes. And they were usually found at home.

REHM

10:10:09
At home.

MARTIN

10:10:10
Yes.

REHM

10:10:11
And turning to you, Dr. Matthew Miller, this has now moved into the realm of public health, whereas previously it was not part of public health studies.

MILLER

10:10:30
That's right. That -- we live in a country where roughly one in three homes have firearms, and more than half of all suicide deaths are due to firearms. You can't really talk about preventing suicide in the United States without also talking about firearms. As has been noted, firearms are -- both through homicide and suicide, contribute to the second leading cause of death among youth. And among people under 40 years of age, the second leading cause of death is suicide, where roughly half of all of those involved firearms.

REHM

10:11:10
But, Dr. Newman, as you were saying earlier, it is that older group of men who tend to be more vulnerable, who tend to be more likely to use a gun to commit suicide.

NEWMAN

10:11:30
Absolutely. Older men above the age of 75 are an extremely high-risk group, particularly with firearms.

REHM

10:11:37
Why is that, Dr. Martin?

MARTIN

10:11:40
Well, there are lots of reasons why people consider suicide, and one of them, which pertains to the older age group, is feeling as if there's no hope. The window of opportunity for feeling good and being successful and enjoying life closes in in their perception, and so illness many times is a precipitant to suicidal thoughts and being unable to get well without a hope of cure or feeling better. So those factors increase as people get older.

REHM

10:12:16
Dr. Newman.

NEWMAN

10:12:17
Absolutely. And also, being socially isolated is a huge risk. The suicide rate is greater among people who are separated, widowed or divorced and also increase in people that are isolated. And that's very common in older people.

REHM

10:12:31
Dr. Miller.

MILLER

10:12:33
From a public health perspective, what -- the questions that we're interested in are not so much the fascinating question why did a particular person in Boston or Mississippi take his own life, but why, year after year, so many more people in Mississippi died by suicide than in Boston or other places where there are fewer firearms. So it's a question about what's happening year after year at the population level to increase the incidents of suicide in places where firearms are more prevalent.

REHM

10:13:09
And, you know, what kinds of tools are you using to investigate and ultimately, one hopes, answer those kinds of questions?

MILLER

10:13:22
Some of the tools that we're using are traditional epidemiologic studies, case control studies, cohort studies and other studies where you look at people, for example, who died by suicide. And you ask the question, compared to people who lived in the same neighborhood, had the same education level and so forth, what other factors increased -- were more common among people who died by suicide compared to those who didn't? And what's striking is that when you compare people who died by suicide to other people who live in the same area, there are a few characteristics that stand out.

MILLER

10:13:55
One is that people who died by suicide are much more likely to have mental illness, major depressive disorder, substance abuse disorder. But they're also much more likely to have lived in a home with a gun. And that's true not only for old people and for young people. It's true for men. It's true for women. It's true for children. And what's remarkable is that it -- this finding is consistent across every single U.S. study that has been done.

REHM

10:14:21
So, Dr. Martin, if one attempts suicide using something other than a gun, one might be less likely to carry out suicide than with a gun?

MARTIN

10:14:41
Yes, that's actually a very good question. We often rank the choice of suicidal instrument, whether it is slitting of the wrist with a knife or a razor blade or taking of pills or jumping off of a bridge. And usually, when people choose something that is what we call more lethal, such as a gun pointed to the head or in the mouth or jumping off of a bridge, the intent is pretty clear that they do actually want to die.

MARTIN

10:15:12
People who choose less likely, there's a probability that they won't die, like pills overdosing or indirect suicide by abusing drugs or alcohol, there is still a possibility that they want help, that they are asking for help. And so when we see people who choose the more lethal methods, then it's pretty clear that at least at that moment they wanted to die. The question is for those of us in the field of psychology and other areas, at the moment, they may want to die. But in the long term, did they want to die?

REHM

10:15:52
Dr. Miller.

MILLER

10:15:54
Thank you. So in thinking about why, for example, rates of overall suicide are so much higher in places where there are more firearms, you have to -- there are four well-established clinical observations that sort of set the -- help you think about the rationale for why that might be the case. One is that firearms are much more likely to result in death than the other commonly used methods. The second is that many suicidal crises are impulsive, especially among younger people.

MILLER

10:16:26
The third is that the crisis itself is fleeting. The window during which you are vulnerable to acting against yourself is short. It closes quickly. And the fourth is that for people who survive a suicide attempt, the prognosis is actually very good. Fewer than 10 percent of people who survive even a nearly lethal suicide attempt go on to die by suicide thereafter. Thinking about all those together, what you realize is that if you can save someone's life in the short run, you're actually very likely to have saved that person's life in the long run.

REHM

10:17:02
Dr. Newman.

NEWMAN

10:17:04
Yeah. And that's absolutely something that we look at when we actually evaluate people in the emergency room is the lethality of the means because of the unforgiving nature of guns. If somebody overdoses on drugs, which is a pretty common suicide attempt, about three-quarters are going to survive even a pretty serious attempt. And, you know, again, because of the impulsive and episodic nature of it, the more lethal and unforgiving the method, the less likely it is that we're actually going to be able to save the person in the long run.

REHM

10:17:39
Go ahead, Dr. Martin.

MARTIN

10:17:41
Well, interestingly, in talking about attempts versus completions, we know, for example, when we look at the data from 2010, there were 25 attempts for every one successful suicide.

REHM

10:17:54
Attempts then by less lethal means.

MARTIN

10:17:59
In most cases, yes.

REHM

10:18:00
Do you regard that as a call for help?

MARTIN

10:18:04
Absolutely, yes. And I think it's important for us to look at prevention methods. It relates to the impulsivity that we've spoken about before. And because there is that window that Dr. Miller was talking about, if we can intervene or something is not as easily accessible, whether it's prescription drugs or weapons, then we have a better chance of intervening and maybe saving that life.

REHM

10:18:29
Dr. Jana Martin, she is clinical psychologist. She also leads public education efforts with the American Psychological Association. We'll take a short break here. When we come back, we'll talk more and take your calls.

REHM

10:20:05
And as we tackle the tough subject of guns and suicide, joining us now is Lucinda Bassett. She is the author of a book coming out next month titled "Truth Be Told: A Memoir of Success, Suicide and Survival." Good morning, Lucinda. Thanks for joining us.

MS. LUCINDA BASSETT

10:20:32
Good morning, Diane. It's my pleasure to be here.

REHM

10:20:34
I gather your husband took his own life five years ago. Tell us who he was and what happened.

BASSETT

10:20:44
Well, he was my best friend, my partner, my children's father. He was a brilliant businessman. We owned a company called the Midwest Center for Stress and Anxiety, and he was the president of the company, ironically. But he also had a genetic predisposition component of bipolar disorder and depression in his family. His grandfather had been hospitalized for years, was eventually put on lithium and was able to live a somewhat normal life when he was properly treated with the right medication.

BASSETT

10:21:18
Unfortunately, his aunt, who had been put on an antidepressant and was improperly treated, took her life to suicide. David had -- he was bipolar as well, but he was more manic than depressive. And he had episodes of depression throughout his life on and on, on and off. But he never had attempted suicide until about a year before when he actually did take his life in 2007.

BASSETT

10:21:46
And what happened for him is he went through a series of traumatic events that were financially related. And then he became more and more isolated and agitated. And we took him to doctors and put him on medications that weren't right for him. And it was pretty clear to me they weren't right for him because the symptoms got worse. He was hospitalized. He tried to take his life a couple of different times. And, unfortunately, the final time, which he did use a rifle, he was successful.

BASSETT

10:22:20
And I wrote this book because, Diane, at the time, when this happened to myself and my children -- my daughter was at Georgetown Business School and son was in high school, and I was Lucinda Bassett, an anxiety and depression self-help person -- I went looking for help. And I was stunned at how many people first know someone or has had a family member commit suicide. And I was also overwhelmed at how difficult it was to find the right help for him.

BASSETT

10:22:50
I guess that's why I wrote the book. I tried everything. And we tried several different doctors, and he was hospitalized. And, you know, he had really made up his mind the year before. I mean, he wanted to take his life. And I think the frustrating thing for me, Diane, is -- and the reason I wrote this book -- I wrote this book to help those -- the survivors who are really the victims. When you have a family member take their life -- and David was an intelligent, I would say, kind of normal professional businessman.

BASSETT

10:23:25
But due to circumstances and a genetic predisposition -- and honestly, I feel the lack of proper treatment, and, by that, I mean -- I believe if he would've been put on the right medication, I believe he could've been put somewhere where he couldn't have walked out, where he had to have been kept for maybe three to six months and treated on the right medication and been in the right therapy, he'd still be alive today, and that's frustration I live with.

REHM

10:23:53
Lucinda Bassett, she is the author of a book coming out next month titled "Truth Be Told: A Memoir of Success, Suicide and Survival." Lucinda, I gather he was a gun collector, but he used a different type of gun?

BASSETT

10:24:17
Well, that's interesting. He was a gun collector, and he, you know, would go shooting with my son. And he was very, you know, he knew how to handle guns. And when he became suicidal, I had a son come and take all of his guns out of the home. But he went and got another gun. And we didn't even know he had this particular rifle. So we had removed the guns from the home. And he did find a rifle that we didn't know about, and he went up into the mountains and shot himself in the chest. Yes.

REHM

10:24:50
Dr. Newman, Lucinda Bassett talks about improper medication. Give me your sense how difficult it can be to find the right medication for an individual.

NEWMAN

10:25:10
Well, one of the biggest challenges is that because depression is commonly associated with suicide, many times, clinicians put their effort and focus almost solely on treating the depression. The problem is is that most antidepressants don't work that quickly. They make take weeks, if not months, to work. So if a person is acutely at risk to themselves, then antidepressants are not going to be effective at reducing their imminent short-term risk.

NEWMAN

10:25:38
The things that are going to be more successful are often harder for us. For example, involuntary hospitalization, that is something that I've seen in many cases. Despite the fact that in every state a physician can order someone to be held for a certain period of time, many doctors and many families are very reluctant to utilize it.

NEWMAN

10:26:01
Another problem is that sometimes clinicians will focus on depression as a risk factor at the expense of possibly other risk factors that are associated with imminent risks. So, for example, if somebody is having very severe acute panic attacks, that significantly increases their risk of short-term harm, also severe insomnia. And those are conditions that actually can be treated fairly rapidly with medication.

REHM

10:26:29
Dr. Martin.

MARTIN

10:26:31
Certainly, what's really important as well is to -- at the same time, while the medication is being administered, for there to be appropriate psychological work being done at the same time. Many times I have had clients who are on beginning regiments of medication. And the support that they received in therapy with the psychologist is what helps him understand why the medication is not working as well, gives them some actual techniques that they can use, helps you to align a support system while one is waiting for the medication to take effect.

MARTIN

10:27:05
Also, there are many times are side effects that are pretty unpleasant with medication. And having someone involved in therapy and working with the psychologist who can help them identify, yes, this is what you would expect, it'll pass or it won't, psychologists working very carefully with the treating psychiatrist who's administering the medication. All of that teamwork is absolutely essential for us to be able to help people who want to be helped.

REHM

10:27:31
Dr. Miller.

MILLER

10:27:33
Yes. I would just add to that, that the empirical evidence in favor of treating people with depression with antidepressants as a way of reducing the risk of suicide is not very strong. There have been studies -- randomized studies that have looked at the benefit of antidepressant therapy. And it seems to be effective only in people with very severe depression, which may well have been the case here.

MILLER

10:28:04
But for people with moderate or mild depression, the evidence is really quite weak. In addition, one aspect of the very unfortunate case that we're talking about here is that despite efforts to remove guns from the home, the decedent found a way to obtain a gun and shoot himself. That is actually unusual. In general, fewer than 10 percent of people who kill themselves with guns acquire the gun within a two to four-week period before the death.

MILLER

10:28:44
Most of the guns used in firearm suicides are guns that have been in the home for a long, long time. And in thinking about the role of firearms here and generally in preventing suicide in the United States, it's really important to recognize that maybe all deaths cannot be prevented. But that shouldn't keep us from thinking about all those that could be.

MILLER

10:29:09
For example, had this -- had the decedent been a boy or a girl and the gun had not been in the home, it would've been harder for them to obtain a gun under most conditions. And so we shouldn't lose sight of the fact that they did everything they could. And usually that's going to be helpful. Unfortunately, in this case, it wasn't.

REHM

10:29:33
Lucinda, when all guns were removed from the home, your husband must have known that that was happening. Yet he managed to go out and buy or get another gun?

BASSETT

10:29:55
Yes. And also, his first attempt was with medication, not with a gun.

REHM

10:29:59
I see.

BASSETT

10:30:01
He took an overdose of medication and ended up in a psych hospital. And, you know, I think what's frustrating for me and part of my mission -- I mean, clearly, gun control is such an important issue. And I agree with the fact that removing guns from the home or not allowing people who have a history of mental illness to purchase a gun would be such a, you know, an important move for our country. But I guess my mission is to understand that these people are mentally ill. And what I found and what I was frustrated with is that the lack of proper care -- he was not put on antidepressants.

BASSETT

10:30:41
He was actually put on antipsychotics. And what I saw happening is he got much worse. And the symptoms got worse. And the other frustrating thing for me as a wife and a parent is we hospitalized him, and he was there for four or five days. And then they sent him home to us on these medications that weren't really right, and we didn't know what to do. And so it's just this terrible place. As a family member, you feel so helpless, and you see them...

REHM

10:31:12
Yes.

BASSETT

10:31:13
...sinking into this abyss of depression. And they become paranoid and obsessive. And they withdraw from their family, and they don't take care of themselves. And the day this is -- this is the unbelievable thing. The day before his last attempt, I actually took him to his psychiatrist, and I said, please put him back in the hospital. I'm afraid he's going to take his life. And he leaned in, and he said, David, are you going to kill yourself? And David said, absolutely not. And I said, you can't believe him. He -- and the next morning, he shot himself.

REHM

10:31:45
Oh.

BASSETT

10:31:47
And that's what I have to live with. And I believe to this day -- I guess that's what's concerning to me is I believe that if society and the medical community would embrace suicide the way they embraced, for example, cancer, and they -- then a lot of these people could be treated because, as you're all saying, most people who take their lives are mentally ill or that they jump off a bridge, jump in front of a train.

BASSETT

10:32:15
My daughter's best friend's mother was an anesthesiologist, and her beautiful daughter wandered up to the bathroom to find her mother injected with the very medication she used, you know, to work with her people, and she took her life. And I want to say one other thing is that for those who are listening who found the person who took their life, which my daughter found her father, you know, in my mind, the reason she found him is I believe when people take their life, their soul kind of lingers.

BASSETT

10:32:50
And I believe that he brought her to him and that he didn't die alone. She was there. And I talk about that in my book, and I think that's important for people, the survivors. They're -- these are the peopleā€¦

REHM

10:33:02
Indeed. Excuse me, Lucinda. I have to take a little pause here. Lucinda Bassett is the author of "Truth Be Told: A Memoir of Success, Suicide and Survival." And you're listening to "The Diane Rehm Show." Dr. Miller, I want to turn to you because Lucinda Bassett raised the issue of gun laws. And you have said that gun laws may or may not need to change but that social norms should. Tell me what you mean.

MILLER

10:33:45
Sure. So by social norms, I'm talking about the way that we think about firearms and suicide, the narrative that surrounds these issues. Social norms changed back in the 1960s and '70s around driving when inebriated. When I was growing up, you couldn't really turn to your friend and say, you've had too much to drink. I'm driving us home. But, over time, it became acceptable. And that's what I mean by normative. The social norm shifted such that when my friend drinks too much, he or she expects that I'll ask to take the keys and drive home.

MILLER

10:34:27
If we can get to a point where when you see a friend who's struggling or a friend who has teenagers who are struggling, it should be just as easy for me to go to you and say, you know what, it looks like you are having trouble. You're talking about drinking more or about having difficulty sleeping. Why don't we take the guns, put them somewhere temporarily until things settle down? When that becomes more acceptable, we will have the sort of social setting that enables people to remove guns from the home when they're in vulnerable periods. And that itself could have a big effect.

REHM

10:35:05
And, you know, that drunk driving issue came about largely because of the efforts of the group Mothers Against Drunk Driving. We have attempted perhaps to have such movements in this country in terms of having guns in the household. When we see the stats here about how many suicides occur when there are guns in the home, do you think, Dr. Martin, that the mindset, the social norm can be changed?

MARTIN

10:35:56
Yes, I do. I believe that public education is vital to changing behavior and social norms. And, unfortunately, there's -- there hasn't been enough exposure to how simple it is to take care of safe guns in the home. It's very easy to lock them up, to put the ammunition in a different place, to teach children about not playing with guns and firearms.

MARTIN

10:36:21
But it somehow has not really rolled into a national campaign that hits every household. Students are learning about these programs at school, in some schools, about the danger of firearms or other things. And we just need more of a public education effort so that people understand the value of people protecting themselves and their children. It does change lives, and it keeps lives.

REHM

10:36:51
Dr. Newman.

NEWMAN

10:36:53
I think one of the biggest challenges is that, you know, as doctors when we evaluate family members, you have to know that you can actually get the information that you need. And one of the more concerning developments is that many states in the last few years have actually considered legislation -- and Florida actually passed a law in 2011 that restricts the ability of clinicians to even ask questions about firearms in the home. And the original version of the bill in Florida actually suggested great sanctions against doctors who ask these questions.

REHM

10:37:28
Dr. Alan Newman, he is associate professor of psychiatry at the Georgetown University Medical Center. When we come back, your calls.

REHM

10:40:04
And welcome back. We're talking about the relationship between guns and suicide. You've heard what our guests had said. Let's now go to the phones first to St. Louis, Mo. Good morning, Dustin. You're on the air.

DUSTIN

10:40:25
Hi. Good morning, Ms. Rehm. Thank you.

REHM

10:40:26
Certainly.

DUSTIN

10:40:28
I agree absolutely with the talk about education. When people talk about diabetes, people say he has diabetes. But when they talk about depression, they don't say he has depression or he has suicidal tendency. They say that he is depressed, and I think that education is a big part of that. But the conversation doesn't seem to be talking so much about suicide but more about guns. And if one in 25 attempts is successful, then you probably don't have 25 attempts with guns.

REHM

10:41:06
Dr. Newman, do you want to straighten out those statistics?

NEWMAN

10:41:10
Well, I think the number one in 25 sort of refers to, if we look at the entire population, how many attempts are there and then how many deaths are there. And so, for example, you will find some people, for a variety of reasons, who may engage in 15 or 20 overdoses with a low level of lethality, and that would count for an attempt in many people's minds.

NEWMAN

10:41:38
The issue with suicide with guns is that the lethality is so great that the person who chooses the gun as their method of killing themself is probably not going to have 25 attempts. The likelihood that they'll even have a second attempt is extremely high, so the numbers are very high. I think one thing that sometimes is helpful in looking at it is comparing the ratios of men to women. Men are much more likely to use a gun as the method of attempting suicide than women, about twice as likely.

NEWMAN

10:42:10
If you look at completion rates, men complete suicide about four times as much as women in the United States. If you look at attempts, women actually attempt suicide much more often than men, about three times as often. Because women often use means that are not as lethal as firearms, their survival rate is considerably higher.

REHM

10:42:30
For example, pills of some sort.

MARTIN

10:42:33
Certainly. I think also one of the things that the caller is identifying is that there still remains a stigma among society for people who are struggling with emotional difficulties, whereas the diabetes group that he was referencing, they've done a really good job of saying, this is a disorder, and here's how we deal with it. Mental illness is a little bit different, but still, we -- if we see a continued reduction in the stigma, then people are more likely to seek out help. And again, we would prevent suicides as well as homicides, as well as many other problems.

REHM

10:43:10
All right. To Cary, N.C. Good morning, Jeffrey.

JEFFERY

10:43:15
Good morning, Ms. Rehm. Thanks for taking my call.

REHM

10:43:17
Sure.

JEFFERY

10:43:18
Just had a couple of comments and questions here. One, the -- early on, one of your panelists -- I can't recall who exactly -- but mentioning the, you know, suicide attempts in completions with a firearm are by far the largest percentage being, you know, more than 50 percent. I'm just wondering what the second largest would be, and if guns did not exist, would we be after that method, trying to get rid of it?

JEFFERY

10:43:49
And my other comment, kind of on the numbers of these things, also like the previous caller, hearing the statistic of the number of suicides in homes that have guns being high compared to, you know, the epidemiologic study that was mentioned. But then looking at the flip side of that statistic would be, what percentage of homes with guns also have an attempted suicide?

JEFFERY

10:44:16
I think we would find -- I don't know the number, but I'd be curious to hear if the panelists do know this number that are homes with guns more likely to have someone attempt suicide, or is it just that in a home with a gun because that method is more lethal as we've mentioned many times already on your show?

REHM

10:44:35
All right. Dr. Miller, I think you can respond to that.

MILLER

10:44:40
It's an excellent question. So the first part is -- has to do with the statistics. About half of all suicides -- and by suicides, I mean, lethal attempts -- are due to guns. Another 25 percent are due to hanging, another 15 to 17 percent are due to poisonings. When you look at attempts in general, most of which are not lethal, 75 percent or so were due to poisoning, mostly drugs and through drug ingestions.

MILLER

10:45:12
Another 20 percent or so are due to cuttings and piercings. Very few are due to hangings or firearms. So if you work in an emergency room, what you see when people come in alive is mostly poisonings and cuttings. The people who use guns die. And they die in the home. Now, the question, what would people who live in homes with guns do if they didn't have guns, is an excellent question and gets at sort of the central research question with respect to restricting access to means.

MILLER

10:45:45
It turns out that people who live in homes with guns are not more suicidal than people who live in homes without guns. They do not have higher rates of depression. They do not have higher rates of drug abuse. They do not have higher rates of any kind of mental illness nor do they even have higher rates of thinking about suicide or attempting suicide. What they do have is a much higher rate of dying in any given attempt.

MILLER

10:46:08
When we try -- and so this is analogous in many ways to the way that we have come naturally to think about unintentional injuries, like motor vehicle fatalities. When somebody -- when we look back in the 1950s and '60s at rates of fatal motor vehicle crashes, what we saw were the rates that were 90 percent higher than they are today. And for a long time, the question that people ask was, you know, why is this person getting into a crash?

MILLER

10:46:37
Instead of -- and then there was a shift. The question became, why is the injury occurring, why is the person dying? So -- and in asking than different question, we no longer try to understand why people are driving faster or out of control, that's part of the spectrum of normal human behavior, and rather we focused on the injury itself. People were being impaled by the non-collapsible steering columns. They were being lacerated by the glass that was not shatter-proof.

MILLER

10:47:05
And by asking that question and having good data sets in which to analyze these issues, we were able to start building cars that absorb energy, taking trees off the side of roads so that when people lost control, they would roll into a ditch and not smash into a tree. So by asking this question for suicide, why are people dying more so in Montana then Massachusetts, for example, what we come to is the environment, the agent of death in more than half of these guns -- half of these suicides and that is firearm ownership.

REHM

10:47:42
All right. And there's yet another question because, Dr. Newman, you mentioned at the start of the program that men over the age of 75 are the most likely to commit suicide. Am I stating that correctly?

NEWMAN

10:48:03
They are one of the highest groups, yes.

REHM

10:48:05
They are the highest group. Here's an email from Pat, who says, "Until we provide humane ways to end the lives of the suffering, it's probably true that some or many suicides should not be prevented." How do you respond to that?

NEWMAN

10:48:29
Well, it's a very challenging question when you look at issues related to ending somebody's life who has a potentially lethal disease.

REHM

10:48:40
Who's suffering.

NEWMAN

10:48:41
Who is suffering? I do think it is certainly true that when you look at many people who have terminal diseases, who are suicidal, one thing that you find that's very common is that their pain is not adequately managed and that if you adequately manage people's pain, you might address these issues. Another thing is that many people with life-threatening illnesses suffer from profound depression. And just because they have a severe or even potentially fatal illness does not mean that the depression is untreatable.

REHM

10:49:14
But the question underlying that is, is it not? Shouldn't someone be allowed to end his or her life with the help of someone else, with the help of the medical profession if the outlook is so bleak? And that's the underlying part of that question, a different discussion than ours today but nevertheless a very profound and important one. And you're listening to "The Diane Rehm Show." Let's go now to Massillon, Ohio. Good morning, Michael.

MICHAEL

10:50:05
Yes. Good morning. Thank you for taking my call.

REHM

10:50:06
Surely.

MICHAEL

10:50:08
I have a, oh, as much a statement as a question.

REHM

10:50:12
All right.

MICHAEL

10:50:13
It concerns religion. Because although I'm closer to what you might call an agnostic, I do know enough to know that many people -- I don't know how I'm going to put this in the Christian faith. You know, you grew up believing that killing yourself, it's a one-way ticket not to heaven. And does, I guess, does religion play a factor at all in people's choices?

REHM

10:50:43
Dr. Martin.

MARTIN

10:50:44
Certainly it does. There are several things that we look at that we sometimes refer to as protective factors that we find that when these factors are present in a person's life, that suicide is less likely. And religious beliefs, Christianity as well as other religions, a strong belief that one was put here for a reason or a purpose and that it is wrong to take a human life, many times that will keep people from committing suicide.

REHM

10:51:15
All right. To Indianapolis. Good morning, Anne.

ANNE

10:51:19
Good morning. Thank you for taking my call.

REHM

10:51:21
Sure.

ANNE

10:51:21
This topic is heart-wrenching and yet so appropriate. Just a comment and a question. Comment is related to the stigma associated with this that I think sadly the general awareness of the frequency of suicide may even be lower than what the statistics report because there is still such shame that many families feel when their loved one takes their own life through suicide.

ANNE

10:51:47
That was the situation that I'm referring to in my boyfriend's father, who was over the age of 75, took his life with a gun. Yet he pointed it to the struggle he was having with tinnitus or ringing of the ears or tinnitus, I think, it's called. And that was my question for your panel. I did a little research and just found quite a strong correlation between suicide and those suffering from tinnitus or...

REHM

10:52:16
Interesting.

MARTIN

10:52:18
Yes. That's a very painful, very distracting disorder. There is -- there are minimal things that can be done, some of them less in the discomfort but truly not being able to get this ringing noise out of your ears. It sometimes relates to pain as well. We do see a lot of depression related to folks who have no control over this and suicide as well.

REHM

10:52:43
All right. Thank you for calling. Dr. Newman.

NEWMAN

10:52:46
I just wanted to add that there is the number of medical conditions that we see that are similar. I've treated patients with chronic dialysis, patients who have intractable hives. And even though you might think that, well, what's the big problem with itching, but if somebody is truly suffering for years, you know, even conditions that might seemingly be tolerable for a few hours can be associated with higher risks.

REHM

10:53:09
All right. And here's a policy question for you, Dr. Miller, from Tim in Baltimore, "Can you comment on the impact of the Tiahrt Amendment's prohibition on gun violence studies at the CDC?"

MILLER

10:53:30
With respect to suicide, not really. In as much as what much of the legislative efforts Tiahrt and others have focused on is the really important question of the illicit transfer and possession of firearms.

MILLER

10:53:44
But since we know that most -- the vast majority of firearm suicides occur in the home with a gun that's been there for years that's legally possessed and legally acquired, that kinds of legislation that are important in reducing rates of interpersonal violence that occurs on the street are not really going to have an impact on rates of suicide. That's why I talk more about trying to change social norms and getting people to act in their own enlightened self-interest.

REHM

10:54:09
Sure. And, Dr. Newman, just to follow up on something you said earlier, the whole idea of being able as a psychiatrist to ask a patient, do you have a gun in the home? Are you prevented from doing that?

NEWMAN

10:54:35
Currently not, but that's the proposal in many states is to put restrictions on this. And it would put physicians in a tremendous bind because you cannot do a competent suicide risk assessment without inquiring about whether or not guns are present. It's too central to lethal completed suicides. And so, without being able to ask those questions, you cannot have a competent risk assessment. You cannot get the information that you really need to make a good decision about hospitalization, medications, other interventions.

REHM

10:55:06
So how can you proceed? I mean, if you say, as Lucinda Bassett's husband responded, no, I have no intention of committing suicide, and yet he has had access to a gun, he's decided to do it, he does it the next day, it would seem to me it would put you as a psychiatrist in a very uncomfortable place.

NEWMAN

10:55:37
Well, one of the biggest problems with doing these assessments is that if somebody is absolutely committed to ending their own life, they may engage in a lot of deception. Not only might they hide a potential weapon, they may lie to their family, they may lie to doctors.

BASSETT

10:55:53
Right. Right.

NEWMAN

10:55:54
And so one of the things that Ms. Bassett mentioned was that the physician asked her husband directly.

REHM

10:56:01
Exactly.

NEWMAN

10:56:02
One of the things that I've seen in many cases that I've reviewed after somebody has committed suicide is that many clinicians over-rely on asking. Sometimes they'll call this a no-harm contract. They'll ask the person if they're going to promise them that they wouldn't hurt themselves, and it's a tremendous mistake to rely on these so-called no-harm contracts. And you have to be free to get collateral information from family members, from other providers and get other information.

REHM

10:56:33
Doctor...

BASSETT

10:56:33
I want to -- I wanted just to add there. This is Lucinda.

REHM

10:56:35
OK. Very quickly, please.

BASSETT

10:56:39
Very important as a family member to be very involved because these people will lie. They hide their medications, don't take their medications. So it's -- you need to be very involved with the person who is mentally ill and the doctor and be assertive.

REHM

10:56:54
And that is really a good last word. Lucinda Bassett, she is the author of "Truth Be Told: A Memoir of Success, Suicide and Survival" to be published in March next month. Dr. Jana Martin, she is with the American Psychological Association, Dr. Alan Newman of Georgetown University Medical Center, and Dr. Matthew Miller of the Harvard School of Public Health, thank you all so much.

NEWMAN

10:57:32
Thank you.

MARTIN

10:57:32
Thank you.

REHM

10:57:33
And thanks for listening all. I'm Diane Rehm.
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