Owning a handgun is associated with a dramatically elevated risk of suicide, according to new Stanford research that followed 26 million California residents over a 12-year period. The higher suicide risk was driven by higher rates of suicide by firearm, the study found.

Men who owned handguns were eight times more likely than men who didn’t to die of self-inflicted gunshot wounds. Women who owned handguns were more than 35 times more likely than women who didn't to kill themselves with a gun.

While prior studies have found higher rates of suicide among people who live in homes with a gun, these studies have been relatively small in scale and the risk estimates have varied. The Stanford study is the largest to date, and it’s the first to track risks from the day of an owner’s first handgun acquisition.

“Our findings confirm what virtually every study that has investigated this question over the last 30 years has concluded: Ready access to a gun is a major risk factor for suicide,” said the study’s lead author, David Studdert, LLB, ScD, MPH, professor of medicine at Stanford Health Policy and of law at Stanford Law School.

The study published in The New England Journal of Medicine analyzed data on handgun acquisitions and deaths in a cohort of 26.3 million adult residents of California who had not previously owned handguns. The researchers followed the cohort from 2004 through 2016, and compared death rates among those who did and didn’t acquire handguns, with a particular focus on suicides by firearm versus other methods.

More than 1.4 million cohort members died during the study period. Nearly 18,000 of them died by suicide, of which 6,691 were suicides by firearms.

Often Impulsive Acts

“Suicide attempts are often impulsive acts, driven by transient life crises,” the authors write. “Most attempts are not fatal, and most people who attempt suicide do not go on to die in a future suicide. Whether a suicide attempt is fatal depends heavily on the lethality of the method used — and firearms are extremely lethal. These facts focus attention on firearm access as a risk factor for suicide especially in the United States, which has a higher prevalence of civilian-owned firearms than any other country and one of the highest rates of suicide by firearm.”

There were 24,432 gun suicides in the United States in 2018, according to the Centers for Disease Control and Prevention. Three-quarters of them involved handguns. 

The Stanford study took advantage of the unusually comprehensive body of information on firearm sales in California. All lawful gun purchases and transfers must be transacted through a licensed firearms dealer, who then relays the information to the state’s Department of Justice, where it is archived. The research team obtained records of all firearm acquisitions dating back to 1985, then linked them to death records. 

The researchers found that people who owned handguns had rates of suicide that were nearly four times higher than people living in the same neighborhood who did not own handguns. The elevated risk was driven by higher rates of suicide by firearm. Handgun owners did not have higher rates of suicide by other methods or higher rates of death generally.

The researchers said the very high risk of suicide for female handgun owners, relative to female nonowners, was particularly noteworthy. It has long been known that women attempt suicide more frequently than men but have fewer completed suicides. The standard explanation is that the methods women tend to use are less lethal than those men tend to use. However, the study showed that this is not true for female gun owners.

“Women in our cohort who owned guns and died by suicide usually used a gun,” said Yifan Zhang, PhD, a biostatistician at Stanford Health Policy and co-author of the study. “Handgun ownership may pose an especially high risk of suicide for women because of the pairing of their higher propensity to attempt suicide with access to and familiarity with an extremely lethal method.”

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Disentangling Competing Explanations

One major challenge with studies examining the relationship between gun access and suicide risk has been determining whether people who purchase handguns already have plans in place to harm themselves, or whether the presence of a handgun creates new risks.

The unique, longitudinal nature of the Stanford study helped to disentangle these competing explanations.

“There appears to be some of both happening,” said senior author Matthew Miller, professor of health sciences and epidemiology at Northeastern University. “New handgun buyers had extremely high risks of dying by firearm suicide immediately after the purchase. However, more than half of all firearm suicides in this group occurred a year or more later. Consistent with prior work, our findings indicate that gun access poses a substantial and enduring risk.” 

Other Stanford co-authors of the study are research analyst Lea Prince, PhD, and research assistant Erin Holsinger, MD — both at Stanford Health Policy; and Jonathan Rodden, PhD, professor of political science.

Researchers at Erasmus University, in the Netherlands, and the University of Melbourne, in Australia, also contributed to the work.

The research was supported by the Fund for a Safer Future and the Joyce Foundation, as well as Stanford Law School and the Stanford University School of Medicine.

A team of SHP faculty and researchers, together with Stanford Medicine graduate and medical students and in collaboration with colleagues at CIDE in Mexico, have launched a modeling framework to investigate the epidemiology of COVID-19 and to support pro-active resource planning and policy evaluations for diverse populations and geographies — including California, Mexico and India.

The Stanford-CIDE Coronavirus Simulation Model — or SC-COSMO — incorporates realistic demography and patterns of contacts sufficient for transmission of the virus that has infected more than 2 million people worldwide and claimed more than 125,600 lives, according to the widely used Johns Hopkins COVID-19 map which is updated several times a day.

The SC-COSMO model also incorporates non-pharmaceutical interventions, such as social distancing, timing and effects on reductions in contacts which may differ by demography.

Jeremy Goldhaber-Fiebert, an associate professor of medicine at Stanford Health Policy, is the principal investigator of the project, along with Fernando Alarid-Escudero, an assistant professor at the Center for Research and Teaching in Economics (CIDE) in Mexico and Jason Andrews, an assistant professor of medicine (infectious diseases) at Stanford Medicine. Other SHP faculty among the 20 investigators and staff members who are working on the project are Joshua Salomon and David Studdert, both professors of medicine.

The SC-COSMO team is a multi-disciplinary, multi-institutional team including expertise and experience in infectious disease, epidemiology, mathematical modeling and simulation, statistics, decision science, health policy, health law and health economics.

“As COVID-19 transmission occurs throughout the world’s diverse populations, it is critical to efficiently model and forecast its future spread between and within these populations and to appropriately reflect uncertainty in modeled outcomes,” Goldhaber-Fiebert said. “Doing so supports timely resource planning and decision making between potentially appropriate and effective interventions that balance the trade-offs they embody.”

The team is currently working on three projects:

1. The researchers are providing California with county-level COVID-19 estimates for such things as the number of infections, detected cases and projections of future needs for hospital and ICU beds, personal protective equipment (PPE) and ventilators.
2. The project is working on potential strategies to mitigate the COVID-19 pandemic in Mexico by focusing on three specific objectives: collecting, synthesizing and openly sharing the most relevant and useful data; accelerating the development of the SC-COSMO model and its adaptation to the Mexican situation; and identifying a set of mitigation strategies, comparing the health and economic consequences in the population in the medium and long term.
3. They are developing forecast models of the COVID-19 epidemic in India with the Wadhwani Institute of Artificial Intelligence and its Indian government partners, providing a rapid response to urgent needs for planning and resource allocation.

Half of the medical students in the United States are women, as are two-thirds of the health-care workers taking care of patients in hospitals, clinics and residential communities.

And the majority of the nurses on the frontlines of the COVID-19 pandemic? Women.

Yet gender bias and workplace harassment continue to plague women who have dedicated their careers to taking care of others.

A classic example given by Michelle Mello in a Perspective published in this week’s New England Journal of Medicine goes like this: A female attending physician and a male resident respond to a call to the emergency department. The ED staff direct questions about medical decisions to the man, addressing the logistics to the woman.

“The resident looks awkwardly at the attending but says nothing,” Mello writes. “Gesturing at the attending, the patient says he hopes `the hot new nurse is going to be mine.’ Everyone ignores the comment.”

Sexual harassment and gender bias remain highly prevalent in medicine, ranging from the banal comments by the patient in the scenario above to aggressive misconduct that can damage female health professionals’ well-being, careers and quality of care.

Healthcare organizations have formal processes in place to respond to complaints of workplace discrimination, but these processes “are insufficient to transform cultures,” writes Mello, a professor of medicine with Stanford Health Policy and a professor of law with Stanford Law, and her co-author Reshma Jagsi, director of the Center for Bioethics and Social Sciences at the University of Michigan.

Health-care professionals of both genders must speak up.

“We believe health professionals have a moral duty to practice `upstanding’ — intervening as bystanders — in response to sexual harassment and general bias and that this obligation should be described in codes of medical professional ethics and supported within institutional training,” the authors write.

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While many medical professional societies now mention sexual harassment in their ethical codes, these guidelines fall short in that they do not encourage professionals to respond to the behaviors and intervene when they become aware of discrimination or harassment. The only large specialty society whose guidelines contain “aspirational advice” to stop sexual harassment in its tracks is the American Association of Orthopaedic Surgeons.

The American Medical Association (AMA) Code of Ethics Opinion 9.1.3 requires only that physicians “promote and adhere to strict sexual harassment policies in medical workplaces.” Mello and Jagsi note a striking contrast to the AMA’s approach to physicians who appear to be impaired (for example, due to substance use or mental health problems): Opinion 9.3.2. requires that physicians “intervene in a timely manner” to ensure that impaired colleagues stop practicing and get help.

“Absent stronger exhortation from within the profession, the norm will continue to be that clinicians are lauded when they stand up to harassment or bias but do not feel obligated — and they are not trained and equipped — to do so,” the authors write.

They recommend formal training in bystander intervention and peer-to-peer coaching, using tip sheets describing various courses of action, like this one adapted from Mary Rowe, an adjunct professor of negotiation and management at MIT Sloan.

A policy brief by the Stanford Institute for Economic Policy Research (SIEPR) by several of our faculty members.

By Maria Polyakova, Jason Andrews, Stephen Luby and Jeremy Goldhaber-Fiebert

Even as people follow the rules of social distancing during the coronavirus pandemic, many still ask how they can best keep themselves safe when it comes to grocery shopping or being in situations where others are clustered. Should I wear gloves? And what about masks? Once businesses reopen and people head back to stores and restaurants, will wearing a medical mask still offer a smart level of protection?

The United States, Austria and some other countries outside of Asia — where mask use is already much more common — are now starting to consider recommending or are already requiring that people wear medical masks in public.

But the World Health Organization still recommends against wearing medical masks as long as you’re feeling well. The big reasons, they’ve argued, is that masks are ineffective and may increase risk to those who wear them incorrectly.

That recommendation deserves reconsideration, especially as policymakers think about what steps can be taken to ensure public safety while allowing more economic activity to resume.

What the Evidence Shows

Empirical evidence from existing observational studies and randomized trials supports the effectiveness of medical masks in reducing transmission of respiratory infections in a variety of settings.

Most observational studies, particularly around the SARS outbreak, have found mask wearing protects against infection. The evidence from randomized trials has been more mixed.

Several trials, conducted in community and health care settings, showed that wearing masks — when combined with thorough handwashing — proved to protect against respiratory infections, while other trials found no benefits. In many of these studies, less than 50 percent of participants actually used the protective measures, so that if more people take up these measures in the face of the pandemic, the benefit may be larger than what was found in the trials.

The most comprehensive reviews of the literature on the effectiveness of masks for interruption or reduction of the respiratory virus spread were conducted by Jefferson et al. in a 2011 Cochrane report and MacIntyre and Chughtai’s 2015 overview of the evidence.

Both reviews concluded that existing research supports the notion that having people wear masks makes good sense. Even if it can’t be measured with absolute certainty how much masks alone are responsible for cutting infection rates, there is no evidence to suggest that wearing a mask is dangerous for one’s health.  Both reviews acknowledge that the design, sample size, and analyses of the underlying studies are frequently non-ideal, limiting definitive conclusions on effectiveness. Nevertheless, the balance of evidence suggests a benefit of mask use in community settings, including among those who aren’t feeling sick, especially when masks are deployed early with respect to exposures and used in conjunction with other measures.

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What Policymakers Can Do

As recently pointed out by some scientists following COVID-19, WHO’s recommendation against the use of masks by healthy people in community settings is based on the interpretation of this existing body of research as providing no evidence for the effectiveness of mask use in the community. The Centers for Disease Control and Prevention had followed a similar interpretation in the U.S., though both it and the WHO recommend the use of masks for symptomatic patients and health care professionals as effective means of preventing transmission.

While the quality of evidence supporting the effectiveness of masks in health care settings is certainly better, the firm recommendation against masks in community settings appears incompatible with the available evidence.

The strength of the recommendations against wearing masks appear to stem from two additional concerns: that the public would wear masks incorrectly, undermining their effectiveness; and that wide-spread community use would exacerbate mask shortages for health care professionals.

The World Health Organization has indicated that wearing masks incorrectly can increase one’s risk of infection. But there is not sufficient evidence to support the notion that people could not wear masks effectively. Many masks are packaged with detailed instructions for how to use them. And online videos could easily be posted to teach people how to wear a mask correctly. The theoretical risk of increasing acquisition of infection, while frequently cited by authorities, does not seem to be supported by a finding of increased risk in any of the available studies.

Appeals to the public not to stockpile masks so as to keep them available for health care professionals have generally not been effective, with widely reported stock-outs and shortages despite such appeals. We speculate that such appeals failed because the general public did not find the argument that masks are ineffective in community settings to be credible.

Moreover, it is possible that initial (and ongoing at the time of this writing) WHO and CDC guidelines against the use of masks in the community by individuals without symptoms may have unintentionally decreased the required sense of urgency and commitment of private and public resources for addressing underlying mask shortages for the general population. The result is that acute shortages of masks undercut even existing CDC recommendations; many individuals who are ill or visiting a health care facility with suspected COVID-19 symptoms cannot obtain masks.

Revising recommendations for expanding the use of masks in public areas in the U.S. is justified by the evidence. And guidelines to wear masks as part of other public efforts — including social distancing — to control the spread of COVID-19 could help steer the production energy and resources of both private and public players to ensuring there are enough masks for everyone.

Supporting the Economy

We further speculate that deployment of masks in public areas may eventually help the economy with transitioning into the post-COVID world.

First, masks could prove to be a cost-effective way of trying to reduce re-emergence of the virus in the medium run, as epidemiologic models suggest that virus re-emergence may necessitate re-introduction of social distancing measures with some regularity over the course of next 12 to 18 months (Flaxman et al. 2020). But wearing masks could give some hope of removing the need to put the economy into the switch on, switch off mode — which would require many businesses to close, open, and close again on short notice

Second, once official restrictions on many forms of economic activity are lifted, it is very likely that consumers will be hesitant in returning to their pre-pandemic levels of consumption of goods and services outside of their homes. Consumers’ behavioral sentiments are crucial for charting course of economic activity, while prolonged uncertainty may be harmful for firms (Bloom 2009).

Having a mask and knowing how to use it may serve as an extra crutch to help with inevitable consumer anxiety.

Policy Brief References