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Ann Marie T. Sullivan, M.D., Commissioner
Governor Andrew M. Cuomo

Means Restriction

Gary L. Spielmann, M.A., M.S.
Director of Suicide Prevention
New York State Office of Mental Health

Limiting access to lethal means of self-harm is an effective strategy to prevent self-destructive behavior, including suicide. Some suicidal acts are impulsive, resulting from a combination of psychological pain or despair coupled with easy availability of the means to inflict self-injury: firearms, carbon monoxide, medications, sharp objects, tall structures. By limiting the individual's accessibility to the means of self-harm, a suicidal act may be prevented. The goal is to separate in time and space the individual experiencing an acute suicidal crisis from easy access to lethal means of self-injury and personal harm. The hope is by making it harder for those intent on self-harm to act on that impulse, one can buy time for the crisis to pass and for healing and recovery to occur.

A study by Dr. Richard Seiden of 515 people who were prevented from jumping from the Golden Gate Bridge to a near-certain death found that 26 years later, 94% of the would-be suicides were either still alive or had died of natural causes. The study, Where Are They Now? (1978) "confirmed previous observations that suicidal behavior is crisis-oriented and acute in nature. It concluded that if a suicidal person can be helped through his/her crises, one at a time, chances are extremely good that he/she wont die by suicide later." (Friend: 2003)

The value of means restriction also pertains to adolescent behavior. "When vulnerable kids crack, the weapons that are at hand make the consequences of that vulnerability more serious." (JJ Mann in Goode: 1999) According to the Centers for Disease Control and Prevention (CDC), the rate of firearm death in the United States of children ages 0 to 14 is nearly 12 times higher than in the 25 other industrialized nations combined. More than 800 Americans, young and old, die each year from guns shot by children under the age of 19.

In New York, firearms were used in 33% of all suicides in 2002, and in approximately 28% of those between 15-24 years of age. (CDC: 2005) A 2004 study examined the association between youth-focused firearm laws and suicides among youth in 18 states. The study's author concluded that as many as 300 lives have been saved as a result of laws that require guns to be safely stored away from children. Laws that raised the required age of gun buyers and owners, however, did not significantly reduce suicide rates. (Webster et al.: 2004)

Firearms are the most common method of completed suicides nationwide (54%), followed by suffocation (20%), poisoning (17.5%), falls (2.3%), cut/pierce (1.8%), and drowning (1.2%) (CDC: 2005). This is true for men, women and adolescents who complete suicide. In New York, firearms are also the predominant means of suicide, but by a much slimmer margin. Suicide by firearms seems to be associated with their availability in the home and with victim intoxication. Many homes contain guns and nearly half (43%) of all homicides and suicides occur in a home. Most victims are shot: 67% of the homicides and 54% of the suicides in 2002 (CDC: WISQARS, 2005). In some studies, handguns pose the greatest risk.

Several studies have shown that the mere presence of a firearm in a home significantly increases the risk of completed suicide. This holds true for the population as a whole and for every age group.(Miller, Hemenway and Azrael: 2004) A recent national study (2003) found that having a gun at home is a risk factor for adults to be fatally shot (gun homicide) and to die by one's own hand (gun suicide). The adjusted odds ratio for suicide by gun increased by a factor of 16 compared to homes with no guns. (Wiebe: 2003) Another study concluded that the purchase of a handgun from a licensed dealer was associated with becoming a suicide victim (Miller, Hemenway and Azrael: 2004).

Most children older than age 7 have the strength to pull the trigger of a firearm, especially a handgun, so that restricting access to a loaded weapon would also decrease the chances of an accidental shooting leading to death or injury. Finally, "methods used in fatal suicide attempts differed from those commonly used in attempts overall." (Miller, Hemenway and Azrael: 2004) When it comes to surviving a suicide attempt, the choice of means employed is critical. Most victims who use a firearm do not survive. Other means are more forgiving. Regardless of the means employed, two routes to means restriction are: education and technology.

Educational Initiatives

Educating the public is an important strategy for shaping behavior. The impact of stricter gun control laws on suicide rates has been evaluated in a small number of studies. A gun control law in Ontario was followed by a decrease in firearm suicides. A District of Columbia handgun control law was followed by a decrease both in homicides (-25%) and suicides (-23%). New York City has one of the most stringent handgun control laws of any jurisdiction in the country. It also has one of the lowest suicide rates as well.

To further reduce the rate of suicide by firearm, the American Academy of Pediatrics recommends that parents and others who possess firearms should be educated to:

Those who don't own a gun should be educated to:

Parents and/or guardians of children and adolescents experiencing substance abuse or emotional disturbance problems should be informed that these individuals may use lethal firearms or another means of self-injury if these means are not safely secured. To reduce the threat of ingesting poison, parents should be made aware of safe methods for storing and dispensing common pediatric medications, as well as household toxics. Physicians should be encouraged to prescribe medications that are efficacious but not lethal for those that are lethal, e.g. desipramine and other tricyclic antidepressants, when treating an at-risk suicidal patient.

Safety Technologies

"Every two weeks, on average, someone jumps off the Golden Gate Bridge" into the 55-degree water of San Francisco Bay some two hundred and twenty feet below. "It is the worlds leading suicide location." Since the 1950's, the idea of building a barrier to prevent would-be jumpers from completing their suicide has been hotly debated. Dr. Lanny Berman, the executive director of the American Association of Suicidology, says, "Suicidal people have transformational fantasies and are prone to magical thinking, like children and psychotics…Jumpers are drawn to the Golden Gate because they believe it's a gateway to another place. They think that life will slow down in those final seconds, and then theyll hit the water cleanly, like a high diver." (Friend: 2003). They rarely do. Most die by multiple blunt-force trauma. Others drown in the three hundred and fifty feet of water beneath the bridge. Only 2 in 100 jumpers survive.

"Survivors often regret their decision in midair, if not before. Ken Baldwin and Kevin Hines both say they hurdled over the railing, afraid that if they stood on the chord they might lose their courage. Baldwin was twenty-eight and severely depressed on the August day of 1985 when he told his wife not to expect him home until later. "I wanted to disappear," he said. "So the Golden Gate was the spot. Id heard that the water just sweeps you under." On the bridge, Baldwin counted to ten and stayed frozen. He counted to ten again, then vaulted over. "I still see my hands coming off the railing," he said. As he crossed the chord in flight, Baldwin recalls, "I instantly realized that everything in my life that I'd thought was unfixable was totally fixable - except for having just jumped." (Friend: 2003)

Through the years, efforts to thwart would-be jumpers have been made, but no physical barrier exists today to do so. Objections have been raised to installing a barrier above the four-foot high railing on the grounds of aesthetics, obstructed views, and cost. Even though they are decidedly low-tech, barriers have worked on other high structures. "The Empire State Building, the Duomo, St. Peter's Basilica, and Sydney Harbor Bridge were all suicide magnets before barriers were erected on them. At all of these places, after the barriers were in place the number of jumpers declined to a handful, or to zero." (Friend: 2003)

The current system for preventing suicide on the Golden Gate is what officials call the "non-physical barrier." This includes "numerous security cameras, thirteen telephones, which potential suicides or alarmed passers-by can use to reach the bridges control tower. The most important element is randomly scheduled patrols by the California Highway Patrolmen and Golden Gate Bridge personnel in squad cars and on foot, bicycle, and motorcycle." (Friend: 2003) Despite these countermeasures, the jumpers continue to plunge at the rate of one suicide every two weeks. More recently, The Board of Directors of the Bridge has voted to explore installing a barrier and is seeking $2 million for studies and preliminary designs of a barrier. (Blum: March 20, 2005)

While New York does not have the Golden Gate, it does have at least two bridges like it: the George Washington and Verrazano Narrows. Neither attract would-be suicides the way that the Golden Gate does. In fact, the suicide rate in New York City, where both bridges are located, is below the statewide average. Within the New York City rate, however, is an interesting contrast: suicides by jumping were highest in Manhattan, site of the tallest buildings in the world, and lowest in Staten Island, largely devoid of buildings over 7 stories high. (Marzuk et al.: 1992) In another study in New York, 81 percent of all suicides jumped from their own residences (Fischer et al.: 1993)

Following five student suicides, New York University has turned to physical barriers to deny access to jumping-off sites on campus. More than 179 balconies will now have restricted access. NYU's safety consultant called the move a "rational step." "What you have is a systems approach that makes it less easy for someone to take impulsive action. It is no different from putting up fences to prevent suicide on the Golden Gate Bridge." (Arenson: March 30, 2005) The move to restricted access is not without controversy: the student newspaper at NYU described the installation of barriers as "a face-saving way for NYU to ensure that students don't end their lives on NYU's campus, rather than a way to reach out to suicidal students and offer them help and guidance." (Arenson: March 30, 2005) Meanwhile, the University has also expanded counseling services, promoted mental health literacy, and increased access to information on depression and related disorders for its students.

Another example of technology successfully reducing suicide deaths is the conversion in England in 1963 from deadly coke gas to a less lethal natural gas for home use. There was little substitution to more available means such as hanging or drowning and within a few years, the overall suicide rate was reduced by one-third. (Seiden: 1978) To make a major impact on our own suicide rate, safety technologies that make discharge of firearms less likely should be made more widely available. A law signed by Governor Pataki in 2000 has helped to achieve this goal. It requires firearms retailers to include a child safety locking device with all purchases; post notices regarding safe storage of guns in their place of business; and include gun safety information with the purchase of any gun. Failure to comply with this law is punishable as a class A misdemeanor.

This law also places a ban on assault weapons; raises the minimum age to obtain a permit to purchase a handgun to 21 years old; implements a DNA for Handguns program; establishes a gun trafficking interdiction; and directs a study to be conducted on "smart gun" technology. In signing this law, Governor Pataki said: "While New York State leads the nation with a 39 percent drop in violent crime since 1994, we still have too much gun violence in our communities. Each year more New Yorkers are killed by guns than die in car crashes and that must change. This new law will help." (Pataki: 2000) Recent statistics on the use of firearms in suicides show this change is occurring.

A recent study, published in the Journal of the American Medical Association on February 9, 2005 found that locked guns appear to offer the most protection against accidental death and injury or during a suicide attempt. Any one of the four storage methods, including keeping guns and ammunition in different locations, cuts the risk of death and injury by between 55 and 73 percent. (Grossman et al: February 9, 2005) The study found that when guns are stored unloaded, locked and separate from ammunition, this practice offers the most protection against accidental or suicidal use. "Doctors who treated suicidal teens should use the study to reinforce the effectiveness of keeping guns securely locked and inaccessible," said Jerry Reed, executive director of the Suicide Prevention Action Network. "It just seems appropriate we would look at this just like we would storing poison under the sink." Finally, we should recognize the limits of means restriction. In New Jersey, there has been a rash of "suicides by locomotive", where people deliberately place themselves in front of moving commuter trains traveling at high speeds. Because rail lines are so extensive, fences are not a real deterrent to someone who is determined to gain access to the railroad tracks. Death on the tracks - at a rate of about 25 a year - has become a regular occurrence. The New Jersey Transit Authority has responded by providing a regular counseling program for train crews who respond to these grisly suicidal incidents. (Smothers: 2003)

As noted, a possible outcome of restricting one specific means of self-harm is the substitution of another means in its place. This has apparently been the case for American adolescents, ages 10-14, between 1992-2001 (CDC: 2004). Over this period, rates of suicide using firearms and poisoning decreased, whereas suicides by suffocation increased. By 2001, suffocation (asphyxia/hanging) had surpassed firearms to become the most common method of suicide death for this age group. The reasons for this change in suicide methods are not fully understood. However, tougher handgun laws, the private nature of suffocation, its widespread availability, and its high lethality suggest that population-based prevention efforts must address the underlying reasons for suicidality to avoid the potential for method substitution. (CDC: 2004) In 2002, suicide was the 3rd leading cause of death for persons age 15-19 in New York. (CDC: 2005)

Given the many means of ending one's life, restricting access by confining those at suicidal risk to institutional settings has been considered. In most cases, this is a difficult proposition to justify. While many people who die by suicide possess multiple risk factors, many more will not die by suicide. Confinement in a safe and secure facility for the vast majority of these at-risk individuals would be counterproductive. "The great number of false positives would result in commitment of large numbers of patients not in need of such treatment (and control). This inability to predict the outcome would probably be the result of any attempt to predict a rare occurrence." (Kaufman and Doty: 2002)

10 Leading Causes of Violence-Related Injury Deaths, 2001, All Races, Both Sexes

Ten Leading Causes of Violence-Related Injury Deaths, 2001, All Races, Both Sexes

* Not elsewhere classifiable.
Produced by: Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC.
Data Source: National Center for Health Statistics (NCHS) Vital Statistics System.


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