How to Lower the Suicide Rate

In order to reduce deaths by suicide, many mental health experts strongly support the reform of American gun laws. The facts about suicide are on their side: In the United States, more people die by a self-inflicted gunshot than all other suicide methods combined. Several studies have shown that firearm owners are far more likely to use a gun to attempt suicide than to defend their families from an intruder. States with higher rates of gun ownership also tend to have higher suicide rates.

Suicide attempts are often impulsive acts, and the presence of a firearm can turn a momentary crisis into a fatal tragedy. A self-inflicted gunshot is the most lethal — the least survivable — form of attempted suicide. Even those who survive, thanks to the heroic efforts of emergency responders, are likely to face lifelong disfigurement and disability.

However, the Second Amendment to the U.S. Constitution presents a potentially insurmountable barrier to the kinds of reforms that many mental experts say they desire. For example, a ban on the private ownership of handguns, the most commonly used type of firearm in suicides, is a highly improbable political outcome. A casual perusal of online "prediction markets" shows that firearm bans are not even being contemplated by amateur futurists willing to put money on their guesses. There are more guns in the United States than there are automobiles; it is hard to imagine a future political scenario in which the total confiscation of privately held firearms, such as occurred in Australia in the 1990s, might occur.

Access to firearms is indeed a potent risk factor for death by suicide. However, so is alcohol use:

• An estimated 10 to 15% of people who are dependent on alcohol eventually die by suicide.
• The lifetime suicide risk for people with alcohol disorder is higher than for people with mood disorders.
• A 40-year longitudinal study of Norwegian conscripts found that alcohol abusers were nearly seven times more likely to die by suicide than non-abusers.
• In a psychological autopsy study of 141 suicide decedents in New York City, 56% were found to have been alcohol abusers.
• Alcohol is detected in the blood of nearly 30% of American suicide decedents.
• Alcohol is one of the five most commonly detected drugs in fatal suicidal overdoses.
• Alcohol abuse is a powerful driver of two crucial factors in male suicide — unemployment, and divorce. (Males comprise 75 to 80% of suicide decedents in the United States.)

Reform of alcohol use regulation in the United States could have a positive impact on the national suicide rate. When Mikhail Gorbachev launched an anti-alcohol campaign in the Soviet Union in the 1980s, the suicide rate decreased by 40%. A recent study in Russia found that a one-liter increase in per capita vodka consumption increased male suicides by 9.3% and female suicides by 6.0%. One of the primary reasons that Russia has been benefiting for more than a decade from yearly decreases in its national suicide rate is that its per capita consumption of alcohol has also been steadily falling.

The United States experienced its own "anti-alcohol campaign" in the form of Prohibition (1920 to 1934). From 1913 to 1916, the average annual suicide rate was 15.4 per 100,000 (which is about 6% higher than the 2017 rate of 14.5 per 100,000). However, after Prohibition went into effect, the average annual suicide rate fell 22%, to 12.0 per 100,000 (1923 to 1926). A similar decrease in the suicide rate today would translate into the saving of more than 10,000 lives.

What could be done, short of a return of Prohibition? First, states could make abstinence from alcohol a condition for all persons on probation or parole. (There are over 4.5 million Americans under such supervision.) Frequent, random calls to report within the hour for breathalyzer testing at a police station at 7 a.m. (and sometimes at 10 p.m.), with immediate brief jail time for offenders would accompany this initiative.

At least one state is experimenting with this method for their first-time DUI offenders (suspending their alcohol privileges instead of their driving privileges, which disrupts employment). Victims of domestic violence and other forms of assault would surely breathe easier knowing that their attackers are barred from experiencing the disinhibiting effects of alcohol. About one in three people arrested in the United States are legally intoxicated. About 40% of people convicted of murder or other violent crimes had been drinking prior to their offense. Alcohol abuse is highly comorbid with Antisocial Personality Disorder.

Second, over-consumption of alcohol could be discouraged in the non-criminal population as well. Senior leadership in the military could direct that underage drinking by troops will result in a dishonorable discharge, as will "habitual drunkenness" among older service members. Colleges could make abstention from alcohol part of their honor codes, close down fraternities, and increase the workload of their students so that they simply do not have the leisure time necessary to abuse alcohol. (Alcohol abuse is more prevalent among the college-educated in the United States than among those who have only completed high school.) Employers could take care never to serve alcohol or otherwise encourage drinking at work-related events.

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Lastly, the sale of alcohol could be subjected to rationing, with no individual able to purchase more than, say, 24 units of alcohol per week. Some form of national alcohol purchasing card would have to be introduced and required at any alcohol point-of-sale, including restaurants. People who consistently reach their weekly limits could be counseled regarding their dangerously high consumption, and perhaps be compelled to attend 3 or 4 motivational interviewing sessions under threat of having their purchasing rights suspended.

I suspect that these proposals sound outlandish and that the chance of them being implemented any time soon seems low. However, unlike firearm ownership, the manufacture, distribution, possession, and consumption of alcohol is not "enshrined in the Constitution." These alcohol reform proposals might be more likely to come to fruition than any further restrictions on gun ownership. Perhaps those of us in mental health who wish to have a positive impact on the suicide rate should focus just as much on alcohol as on firearms.