Firearm suicides among males in Australia: an analysis of Tasmanian coroners' inquest files.
Article Type: Report
Subject: Mental illness (Diagnosis)
Suicide (Psychological aspects)
Suicide (Methods)
Men (Health aspects)
Men (Research)
Authors: Lester, David
Haines, Janet
Williams, Christopher L.
Pub Date: 06/22/2012
Publication: Name: International Journal of Men's Health Publisher: Men's Studies Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 Men's Studies Press ISSN: 1532-6306
Issue: Date: Summer, 2012 Source Volume: 11 Source Issue: 2
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: Australia Geographic Code: 8AUST Australia
Accession Number: 305192593
Full Text: Eighty-nine male completed suicides who used hanging were compared with 388 male completed suicides who used firearms for 45 variables concerning the circumstances of the suicidal act and the personal characteristics of the men. All came from the Australian state of Tasmania during a twenty-year period from 1968-1987. It was found that those choosing firearms less often had a history of suicidal behavior and psychiatric problems, more often were reacting to interpersonal conflict and more often left a suicide note. Thus, the motives and psychodynamics of a potential suicidal act may provide clues to the choice of method for suicide.

Keywords: men, suicide, firearms, hanging

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In a recent study in this journal, Tewksbury, Suresh and Holmes (2010) compared men who commit suicide by firearm with those who use hanging, both considered to be violent methods, in a sample of 419 male suicides in Kentucky. In a multiple regression analysis, older age and a higher body mass index predicted the use of firearms, as did the use of alcohol or drugs prior to the act. Race, marital status, employment, leaving a suicide note, and the location of the suicidal action were unrelated to the choice of method. The present study was based on a series of consecutive suicides in Tasmania (Australia) over a twenty-year period (1968-1987) which has a richer set of variables with which to compare men using these two types of method for suicide. The aim was to see whether the findings of Tewksbury et al. can be replicated and whether additional clues to the choice of method for suicide by men can be ascertained, and so the sample was restricted to men using hanging and firearms for suicide as in the study by Tewksbury et al.

There have many attempts over the years to find differences between those using different methods for suicide. It has long been known that men use more lethal and more violent methods for suicide--firearms rather than overdoses (Lester, 1984)--as do psychiatric patients in general and psychotics in particular (Lukianowicz, 1975). Kaplan et al. (1996) found that the use of firearms for suicides was more common in white males over the age of 65, those living in rural areas, the divorced and widowed and those with less education. Chia, Chia, Ng, and Tai (2011) found that, in Singapore, the use of hanging for suicide (rather than jumping, the two most popular methods for suicide in Singapore) was more common in older individuals, men, and Indians (rather than Chinese or Malay), and they were less likely to leave a suicide note and to have a major psychiatric disorder.

Kaplan, McFarland, and Huguet (2009a) found that military veterans in the United States were more likely to use firearms for suicide than non-veterans (especially those 18-34 years of age), a result probably related to the increased ownership of gun by veterans and their greater familiarity with their use. For the United States in general, Kaplan, McFarland, and Huguet (2009b) found that the use of firearms for suicide was associated with older age, veteran status, raised blood alcohol concentration, and acute crisis and relationship problems, and less common if there was a history of psychiatric illness and attempted suicide. In Taiwan, Chuang, and Huang (2004) found that men and younger individuals were more likely to use firearms for suicide.

It is of greater interest when data on the personal characteristics of the suicides and the circumstances of the suicidal act are available, as in the study by Tewksbury et al. (2010) mentioned above. In Australia, De Leo. Evans, and Neulinger (2002) reported that men who used hanging (rather than firearms and car exhaust) were younger, less likely to leave a suicide note, more likely to have been diagnosed with a psychiatric disorder, more likely to have made prior suicide attempts, and to have no physical illness.

The present study sought to examine the generality of these findings in a sample of 787 male suicides from one region in Australia, 89 of whom used hanging and 388 used firearms.

METHOD

Sample

This research studied 787 male completed suicides from a twenty-year period in Tasmania, Australia (1968-1987). Of these, 89 men completed suicide using hanging while 388 committed suicide using firearms. Following the study by Tewksbury et al. (2010), these two groups were compared.

Information about the cases was obtained from the coroner's inquest files held at the Tasmanian Archives Office and the Tasmanian Department of Justice. All the deaths had been identified by the coroner as being caused by suicide and consisted of all suicides in that period.

There is research which shows that coroners and medical examiners in different countries do not always agree when assigning causes of death (Brooke, 1974). Tasmanian coroners are appointed through the Magistrates Court, and the scope of their powers in described in the website www.magistratescourt.tas.gov.au/divisions/coronial. How the decisions of Tasmanian coroners compare to those made by coroners and medical examiners in other jurisdictions has never been studied.

The present study was based on those male completed suicides who used hanging and firearms. These 477 male suicides had a mean age of 41.6 years (SD = 18.7, range 12-91).

Variables

A possible list of variables was generated and placed on a record sheet. Then 50 files of suicidal deaths were examined which resulted in suggestions for new variables. These were then added to the original record sheet, and another 50 files of suicidal deaths were examined, and further adjustments made to the record sheet. This new record sheet was then applied to the complete sample of suicides.

Data for the following variables were collected from the coroners' files: marital status, age, sex, living arrangements, employment status, suicide history and stated intention, medical and psychiatric history, psychological state prior to the act, psychological symptoms in the days and weeks leading up to the act, reasons for the suicide and method of suicide. Two raters coded the data, and their inter-rater agreement was 97 percent.

Although the inter-rater agreement was high, the data used in this study were based on what information the coroners happened to collect, and the coroners' data were based, in turn, on interviews with the significant others, friends and acquaintances of the suicides. Thus, as with all proxy-derived data, the accuracy of the information is open to question. However, there is no a priori reason to suspect differences in the accuracy of the data based on the choice of method for suicide. Furthermore, the raters were not psychiatrists, and so the criteria for variables such as psychiatric illness are not identical to those the American Psychiatric Association DSM, but rather the opinion of the raters based on the information in the Coroners' files.

The men using hanging versus firearms were compared using chi-square tests (except for age where a t-test was used). The variables significant at the bivariate level were entered into a logistic regression analysis and full and backward regressions computed, b coefficients, standard errors and odds ratios were calculated for each variable in the regression analysis.

RESULTS

The statistically significant findings from the comparison of the men using firearms versus hanging are shown in Table 1. Sixteen significant differences were identified out of 45 comparisons, more than would be expected by chance, ten of which were significant at the .01 level or better.

Those using firearms had a lower average age than those using hanging (mean ages 40.4 vs 46.7), had more often imbibed alcohol prior to the suicidal act (43.6% vs 23.6%), were less likely to have attempted suicide in the past (17.1% vs 36.5%) and more likely to leave a suicide note (34.9% vs 22.5%), had less often visited a physician or psychiatrist in recent months (47.9% vs 64.7% and 22.8% vs 41.3%), were more often angry (28.2% vs 15.7%) and drunk (40.l% vs 20.2%) and less often sad (41.1% vs 58.4%), depressed (24.3% vs 39.3%) and withdrawn (15.8% vs 25.8%), and were more often reacting to conflict with others (47.0% vs 29.2%) rather than avoiding stressful life events (34.4% vs 50.6%).

No differences were found in marital status, employed versus not employed, living arrangements, drugs present post-mortem, suicidal behavior in significant others, prior statement of intent, whether under medical supervision at the time of the suicide, poor physical health, or hospitalization in a general hospital in the past year.

In the days prior to the suicide, the two groups of men were judged to be similar in regards to normal, upset, distressed, erratic, impulsive, confused, cheerful, changeable, or calm. With regard to the motive for suicide, there were no differences in psychiatric illness, physical illness, social isolation, murder-suicide, extrapunition (directing blame or punishment toward others), remorse or modeling. With regard to psychiatric symptoms, there were no differences in agitation, sleep disturbance, withdrawal, anxiety, hypochondria, suicidal rumination or psychosis.

For those variables significant in the bivariate analysis, a logistic regression was run to see which variables predicted the method chosen for suicide. The results for the full logistic regression are shown in Table 2, along with odds ratios. The significant differences were a previous suicide attempt and a recent psychiatric visit, with trends for anger, the presence of interpersonal conflict and avoiding stressful life events (that is, p < .10). In the backward multiple regression, the final significant predictors of the choice of hanging were a previous suicide attempt (b = - 1.27, p < .001), feeling sad in the days prior to the suicide (b = 0.67, p = .029), avoiding stressful life events (b = -0.54, .075), and not reacting to interpersonal conflict (b = 0.92, p = .006).

DISCUSSION

There were many differences between men using firearms and those using hanging for suicide. Both in the univariate analyses (Table 1) and the bivariate analyses (Table 2), the men who used hanging as a means of committing suicide more often had a chronic psychiatric history and faced stressful life events, while those using firearms were angrier, using alcohol at the time of the suicide and reacting to interpersonal conflict.

In agreement with the findings of Tewksbury, Suresh, and Holmes (2010), those using firearms had more often used alcohol prior to the act, but in contrast were younger (Tewksbury et al. found them to be older) and more often left a suicide note (Tewksbury et al. found no differences in leaving a suicide note). Thus, this study illustrates the importance of replicating research in order to ascertain which results are consistently found across samples and which may be unique to the particular sample studied.

Compared to the results of the study by De Leo et al. (2002), the present results replicate the finding that those using hanging were more likely to leave a suicide note and have a history of psychiatric illness and attempted suicide, but those using hanging were older in the present study while they were younger in the study by De Leo et al.

The present study examined a much larger set of characteristics than did Tewksbury et al. and found that those using firearms for suicide seemed to be reacting to current interpersonal conflict and to be angry rather than depressed. Their actions seems to be more impulsive and carried out when under the influence of alcohol. In contrast, those using hanging seem to have experienced chronic problems, accompanied by sadness and depression, and they have a history of medical and psychiatric consultations.

There have been many proposals that restricting access to lethal methods for suicide might be a meaningful tactic for preventing suicide (e.g.. Lester, 2009). This method is used in prisons and jails and in psychiatric institutions where those judged to be at high risk of suicide are placed in "suicide-proof" environments. There is also evidence at the societal level that fencing in bridges and subway platforms, detoxifying domestic gas, and restricting access to lethal substances (such as medications and pesticides) can reduce the suicide rates. With regard to firearms, the evidence is less convincing and efforts to restrict access to firearms have run into political pressure from those who advocate the right to bear arms (especially in the United States). However, the impulsive nature of suicide using firearms identified in the present study supports the use of measures such as delaying purchase of a firearm for several days (by requiring, for example, background checks), storing ammunition separately from the firearms (for those who already own guns) and keeping firearms locked up.

Suicidal individuals have often been classified into two main types--an impulsive response to a time-limited crisis and a chronic maladaptive pattern (Lester & Yang, 1991)--paralleling Becker's (1962) two types of irrational behavior (random erratic and whimsical behavior versus perseverative choices in which the person chooses actions that were chosen in the past). What is of interest is the suggestion in the results of the present study that these two types of suicidal behavior may be associated with choice of a different method for suicide. The choice of method for suicide may, therefore, provide clues as to the motives and psychodynamics of the suicidal act.

For example, in dealing with patients who are contemplating suicide, clinicians are advised to ask the patients whether they have a plan, which method they would use and whether they have the means readily available. The choice of a more lethal method (for example, firearms rather than wrist-cutting), and the possession of the means for the preferred method for suicide indicate a higher level of risk of suicide. The personal and psychiatric nature of the patient's mental state may provide clues as to which method of suicide may be used and, therefore, what precautions should be taken. For example, the senior author recently had contact with an individual with a twenty-year history of mental illness and multiple suicide attempts by overdose who, after being removed from a suicide watch in a psychiatric hospital, hung herself in the hospital. For men involved in interpersonal conflicts and who show signs of distress, persuading them to turn over their firearms to others (at least temporarily) is a reasonable tactic.

One limitation of the study concerns the reliability and validity of the coroner data used. A thorough psychological autopsy study in which a team of researchers conducted detailed investigations of each of the suicides would be methodologically more sound. In addition, we were unable to include deaths ruled as undetermined in our data set (or deaths ruled as accidental that may have been suicides). We limited the data set to only suicides as ruled by the coroners. The strengths of the study are the large sample size and the rich array of variables on which the two groups of male suicides could be compared.

DOI: 10.3149/jmh.1102.170

REFERENCES

Becker, G.S. (1962). Irrational behavior and economic theory. Journal of Politicial Economy, 70, 1-13.

Brooke, E. (1974). Suicide and attempted suicide. WHO Public Health Papers, #58. Geneva, Switzerland: WHO.

Chia, B.H., Chia, A., Ng, W.Y., & Tai, B.C. (2011). Suicide methods in Singapore (2000-2004).

Suicide & Life-Threatening Behavior, 41, 574-583.

Chuang, H.L., & Huang, W.C. (2004). A multinomial logit analysis of methods used by persons who completed suicide. Suicide & Life-Threatening Behavior, 34, 298-310.

De Leo, D., Evans, R., & Neulinger, K. (2002). Hanging, firearm, and non-domestic gas suicides among males. Australian & New Zealand Journal of Psychiatry, 36, 183-189.

Kaplan, M.S., Adamek, M.E., & Geling, O. (1996). Sociodemographic predictors of firearm suicide among older white males. Gerontologist, 36, 530-533.

Kaplan, M.S., McFarland, B.H., & Huguet, N. (2009a). Firearm suicide among veterans in the general population. Journal of Trauma, 67, 503-507.

Kaplan, M.S., McFarland, B.H., & Huguet, N. (2009b). Characteristics of adult male and female firearm suicide decedents. Injury Prevention, 15, 322-327.

Lester, D. (1984). Suicide. In C.S. Widom (Ed.), Sex roles and psychopathology (pp. 145-156). New York: Plenum.

Lester, D. (2009). Preventing suicide: Closing the exits revisited. Hauppauge, NY: Nova Science.

Lester, D., & Yang, B. (1991). Suicidal behavior and Beckers' definition of irrationality. Psychological Reports, 68, 655-656.

Lukianowicz, N. (1975). Suicidal behavior. Psychiatric Clinics, 8, 140-154.

Tewksbury, R., Suresh, G., & Holmes, R.M. (2010). Factors related to suicide via firearms and hanging and leaving of suicide notes. International Journal of Men's Health, 9, 40-49.

DAVID LESTER, Ph.D. *, JANET HAINES, Ph.D. ** and CHRISTOPHER L. WILLIAMS, Ph.D. **

* The Richard Stockton College of New Jersey.

** University of Tasmania.

Correspondence concerning this article should be addressed to David Lester, Psychology Program, The Richard Stockton College of New Jersey, Galloway. NJ. Email: lesterd@stockton.edu
Table 1

Statistically Significant Differences Between Men Using Firearms
and Hanging for Suicide

                                    Hanging (%)    Firearms (%)

Alcohol present                         23.6           43.6
Previous suicide attempt                36.5           17.1
Suicide note                            22.5           34.9
Recent GP visit                         64.7           47.9
Recent psychiatrist visit               41.3           22.8
Under psychiatric supervision           25.3           15.6
Psychiatric hosp in past year           37.5           22.6

In prior days:
  Angry                                 15.7           28.2
  Sad                                   58.4           41.1
  Withdrawn                             25.8           15.8
  Drunk                                 20.2           40.1
Motive
  Conflict                              29.2           47.0
  Avoiding stressful life events        50.6           34.4
Psychiatric symptoms
  Depression                            39.3           24.3
  Alcohol abuse                         18.0           28.4

Age                                 46.7 (19.7)    40.4 (18.3)

                                    [X.sup.2]     df        p

Alcohol present                       12.04        1      0.001
Previous suicide attempt              16.35        l      <.001
Suicide note                           5.08        1      0.024
Recent GP visit                        6.20        l      0.013
Recent psychiatrist visit             10.64        1      0.001
Under psychiatric supervision          4.11        1      0.043
Psychiatric hosp in past year          7.42        1      0.006

In prior days:
  Angry                                5.84        1      0.016
  Sad                                  8.82        1      0.003
  Withdrawn                            5.06        1      0.024
  Drunk                               12.30        1     < .001
Motive
  Conflict                             9.33        1      0.002
  Avoiding stressful life events       8.11        1      0.004
Psychiatric symptoms
  Depression                           8.28        1      0.004
  Alcohol abuse                        4.06        1      0.044

Age                                      t469 = 2.84      0.005

Table 2

Logistic Regression Analysis Predicting Firearm
Use Among Suicide Decedents

Variable                           b coefficient      s.e.

Alcohol present                         0.01          0.83
# Previous suicide attempt             -1.43          0.40
Suicide note                            0.21          0.36
Recent GP visit                        -0.44          0.33
Recent psychiatrist visit              -1.01          0.53
Under psychiatric supervision           0.23          0.64
Psychiatric hosp in past year           0.79          0.56
Angry                                   0.79          0.45
# Sad                                  -0.45          0.39
Withdrawn                              -0.47          0.38
Drunk                                   0.18          0.80
# Conflict                              0.62          0.37
# Avoiding stressful life events       -0.61          0.34
Depression                             -0.10          0.41
Alcohol abuse                           0.11          0.45
Constant                                2.17          0.42

Variable                              P       odds ratio
                                                  (1)

Alcohol present                    ns            2.50
# Previous suicide attempt          < .001       0.35
Suicide note                       ns            1.85
Recent GP visit                    ns            0.50
Recent psychiatrist visit           0.05         0.42
Under psychiatric supervision      ns            0.54
Psychiatric hosp in past year      ns            0.49
Angry                               0.08         2.10
# Sad                              ns            0.50
Withdrawn                          ns            0.53
Drunk                              ns            2.64
# Conflict                          0.09         2.15
# Avoiding stressful life events    0.07         0.51
Depression                         ns            0.49
Alcohol abuse                      ns            1.81
Constant                            < .001

# = statistically significant in a backward multiple regression.

ns = non-significant.

(1) Based on firearms as the critical method.
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