Community-Level Risk Factors for Firearm Assault and Homicide: The Role of Local Firearm Dealers and Alcohol Outlets.

BACKGROUND: Identifying community characteristics associated with firearm assault could facilitate prevention. We investigated the effect of community firearm dealer and alcohol outlet densities on individual risk of firearm assault injury. METHODS: In this density-sampled case-control study of Californians, January 2005-September 2015, cases comprised all residents with a fatal or nonfatal firearm assault injury. For each month, we sampled controls from the state population in a 4:1 ratio with cases. Exposures were monthly densities of county-level pawn and nonpawn firearm dealers and ZIP code-level off-premises alcohol outlets and bars and pubs ("bars/pubs"). We used case-control-weighted G-computation to estimate risk differences (RD) statewide and among younger Black men, comparing observed exposure densities to hypothetical interventions setting these densities to low. We estimated additive interactions between firearm and alcohol retailer density. Secondary analyses examined interventions targeted to high exposure density or outcome burden areas. RESULTS: There were 67,850 cases and 268,122 controls. Observed (vs. low) densities of pawn firearm dealers and off-premises alcohol outlets were individually associated with elevated monthly risk of firearm assault per 100,000 people (RD pawn dealers : 0.06, 95% CI: 0.05, 0.08; RD off-premises outlets : 0.01, 95% CI: 0.01, 0.03), but nonpawn firearm dealer and bar/pub density were not; models targeting only areas with the highest outcome burden were similar. Among younger Black men, estimates were larger. There was no interaction between firearm and alcohol retailer density. CONCLUSIONS: Our results are consistent with the hypothesis that limiting pawn firearm dealers and off-premises alcohol outlet densities can reduce interpersonal firearm violence.

The origins of California's gun violence restraining order law: a case study using Kingdon's multiple streams framework.

BACKGROUND: Firearm violence is a major public health problem in the United States, yet most states lack a mechanism to temporarily remove firearms from individuals who are at high and imminent risk of harming themselves or others and are not otherwise prohibited. Extreme risk protection order (ERPO) laws are intended to close this gap. The current study examines the passage of California's gun violence restraining order (GVRO) bill using Kingdon's multiple streams framework. METHODS: This study was based on an analysis of interview data from six key informants involved in the passage of the GVRO legislation. RESULTS: Findings indicate policy entrepreneurs framed the problem and designed the policy to target individuals at behavioral risk of imminent firearm violence. Policy entrepreneurs comprised an integrated policy network that engaged in a lengthy period of collaboration and bargained with interest groups to yield a bill that satisfied diverse concerns. CONCLUSIONS: This case study may inform efforts in other states to pass ERPO policies and other firearm safety laws.

Extreme Risk Protection Orders in Older Adults in Six U.S. States: A Descriptive Study.

OBJECTIVES: Extreme Risk Protection Orders (ERPOs) allow a court to restrict firearm access for individuals ("respondents") at imminent risk of harm to self/others. Little is known about ERPOs use for older adults, a population with higher rates of suicide and dementia. METHODS: We abstracted ERPO cases through June 30, 2020, from California, Colorado, Connecticut, Florida, Maryland, and Washington. We restricted our analysis to petitions for older (≥65 years) respondents, stratified by documented cognitive impairment. RESULTS: Among 6,699 ERPO petitions, 672 (10.0%) were for older adults; 13.7% (n = 92) of these noted cognitive impairment. Most were white (75.7%) men (90.2%). Cognitively impaired (vs. non-impaired) respondents were older (mean age 78.2 vs 72.7 years) and more likely to have documented irrational/erratic behavior (30.4% vs 15.7%), but less likely to have documented suicidality (33.7% vs 55.0%). At the time of the petition, 56.2% of older adult respondents had documented firearm access (median accessible firearms = 3, range 1-160). CONCLUSIONS: Approximately 14% of ERPO petitions for older adults involved cognitive impairment; one-third of these noted suicide risk. Studies examining ERPO implementation across states may inform usage and awareness. CLINICAL IMPLICATIONS: ERPOs may reduce firearm access among older adults with cognitive impairment, suicidality, or risk of violence.

Neighborhood Racial and Economic Segregation and Disparities in Violence During the COVID-19 Pandemic.

Objectives. To describe associations between neighborhood racial and economic segregation and violence during the COVID-19 pandemic. Methods. For 13 US cities, we obtained zip code-level data on 5 violence outcomes from March through July 2018 through 2020. Using negative binomial regressions and marginal contrasts, we estimated differences between quintiles of racial, economic, and racialized economic segregation using the Index of Concentration at the Extremes as a measure of neighborhood privilege (1) in 2020 and (2) relative to 2018 through 2019 (difference-in-differences). Results. In 2020, violence was higher in less-privileged neighborhoods than in the most privileged. For example, if all zip codes were in the least privileged versus most privileged quintile of racialized economic segregation, we estimated 146.2 additional aggravated assaults (95% confidence interval = 112.4, 205.8) per zip code on average across cities. Differences over time in less-privileged zip codes were greater than differences over time in the most privileged for firearm violence, aggravated assault, and homicide. Conclusions. Marginalized communities endure endemically high levels of violence. The events of 2020 exacerbated disparities in several forms of violence. Public Health Implications. To reduce violence and related disparities, immediate and long-term investments in low-income neighborhoods of color are warranted. (Am J Public Health. 2022;112(1):144-153. https://doi.org/10.2105/AJPH.2021.306540).

Extreme risk protection orders in response to threats of multiple victim/mass shooting in six U.S. states: A descriptive study.

Extreme risk protection orders (ERPOs), also known as red flag laws, are a potential tool to prevent firearm violence, including mass shootings, but little is currently known about the extent of their use in cases of mass shooting threats or about the threats themselves. We collected and abstracted information from ERPO cases from six states (California, Colorado, Connecticut, Florida, Maryland, and Washington). Ten percent (N = 662) of all ERPO cases (N = 6787) were in response to a threat of killing at least 3 people. Using these cases, we created a typology of multiple victim/mass shooting threats, the most common of which was the maximum casualty threat. The most common target for a multiple victim/mass shooting threat was a K-12 school, followed by businesses, then intimate partners and their children and families. Judges granted 93% of petitions that involved these threats at the temporary ERPO stage and, of those cases in which a final hearing was held, judges granted 84% of final ERPOs. While we cannot know how many of the 662 ERPO cases precipitated by a threat would have resulted in a multiple victim/mass shooting event had ERPO laws not been used to prohibit the purchase and possession of firearms, the study provides evidence at least that ERPOs are being used in six states in a substantial number of these kinds of cases that could have ended in tragedy.

Unemployment and Crime in US Cities During the Coronavirus Pandemic.

Unemployment and violence both increased during the coronavirus pandemic in the United States (US), but no studies to our knowledge have examined their association. Using data for 16 US cities from January 2018 to July 2020, we estimated the association between acute changes in unemployment during the coronavirus pandemic and violent and acquisitive crime. We used negative binomial regression models and parametric g-computation to estimate average differences in crime incidents if the highest and lowest levels of unemployment observed in each city had been sustained across the exposure period (March-July 2020), compared with observed unemployment in each city-month. During the pandemic, the percentage of the adult population who were unemployed was 8.1 percentage points higher than expected, on average. Increases in unemployment were associated with increases in firearm violence and homicide. For example, we estimated an average increase of 3.3 firearm violence incidents (95% CI: - 0.2, 6.7) and 2.0 homicides (95% CI: - 0.2, 3.9) per city-month from March to July 2020 if all cities experienced their highest versus observed level of unemployment. There was no association between unemployment and aggravated assault or any acquisitive crime. Findings suggest that the sharp rise in unemployment during the pandemic may have contributed to increases in firearm violence and homicide, but not other crime. Additional research is needed on mechanisms of association, generalizability, and modifying factors.

Gun violence restraining orders in California, 2016-2018: case details and respondent mortality.

BACKGROUND: Gun violence restraining orders (GVROs), implemented in California in 2016, temporarily prohibit individuals at high risk of violence from purchasing or possessing firearms and ammunition. We sought to describe the circumstances giving rise to GVROs issued 2016-2018, provide details about the GVRO process and quantify mortality outcomes for individuals subject to these orders ('respondents'). METHODS: For this cross-sectional description of GVRO respondents, 2016-2018, we abstracted case details from court files and used LexisNexis to link respondents to mortality data through August 2020. RESULTS: We abstracted information for 201 respondents with accessible court records. Respondents were mostly white (61.2%) and men (93.5%). Fifty-four per cent of cases involved potential harm to others alone, 15.3% involved potential harm to self alone and 25.2% involved both. Mass shooting threats occurred in 28.7% of cases. Ninety-six and one half per cent of petitioners were law enforcement officers and one-in-three cases resulted in arrest on order service. One-year orders after a hearing (following 21-day emergency/temporary orders) were issued in 53.5% of cases. Most (84.2%) respondents owned at least one firearm, and firearms were removed in 55.9% of cases. Of the 379 respondents matched by LexisNexis, 7 (1.8%) died after the GVRO was issued: one from a self-inflicted firearm injury that was itself the reason for the GVRO and the others from causes unrelated to violence. CONCLUSIONS: GVROs were used most often by law enforcement officers to prevent firearm assault/homicide and post-GVRO firearm fatalities among respondents were rare. Future studies should investigate additional respondent outcomes and potential sources of heterogeneity.

Physical Distancing, Violence, and Crime in US Cities during the Coronavirus Pandemic.

Violent crime increased and most property crime decreased in many United States (US) cities during the coronavirus pandemic. Using negative binomial regressions, we examined the association between physical distancing (a central coronavirus containment strategy) and crime within 16 large cities (in 12 US states and the District of Columbia) through July 2020. Physical distancing was measured with aggregated smartphone data and defined as the average change in the percentage of the population staying completely at home. Outcome data were obtained from the Gun Violence Archive and city open data portals. In multivariable models, increases in the percentage of the population staying home were associated with decreases in reported incidents of aggravated assault, interpersonal firearm violence, theft, rape, and robbery, and increases in arson, burglary, and motor vehicle theft. Results suggest that changes in the frequency of interpersonal interactions affected crime during the coronavirus pandemic. More research is needed on the specificity of these assocations and their underlying mechanisms.

Armed and prohibited: characteristics of unlawful owners of legally purchased firearms.

BACKGROUND: A substantial proportion of individuals who lawfully purchase firearms later become unlawful owners ('prohibited firearm owners'), usually following events associated with an increased risk for future violence. This high-risk population has not previously been described. We aimed to characterise all individuals in California's Armed and Prohibited Persons System (APPS), a statewide programme for recovering firearms from individuals who legally purchased them and later became prohibited from ownership. METHODS: We used univariate and bivariate statistics to describe and compare prohibited firearm owners in APPS with a random sample of non-prohibited firearm owners in relation to age, sex, race/ethnicity and type of firearms owned as of 1 February 2015. We also characterised the geographical distribution of prohibited firearm owners and described their prohibitions. RESULTS: Of the 18 976 prohibited firearm owners, most were men (93%), half were white (53%) and the mean age was 47 years. Prohibited firearm owners were more likely to be male and to be black or Hispanic people than non-prohibited owners. Both prohibited and non-prohibited firearm owners had an average of 2.6 firearms, mostly handguns. Nearly half (48%) of prohibited firearm owners had a felony conviction. Extrapolating from our findings, we estimated that there are approximately 100 000 persons in the USA who unlawfully maintained ownership of their firearms following a felony conviction. CONCLUSIONS: Retention of firearms among persons who become lawfully prohibited from possessing them is common in California. Given the nationwide dearth of a programme to recover such weapons, this is likely true in other states as well.

News media coverage of extreme risk protection order policies surrounding the Parkland shooting: a mixed-methods analysis.

BACKGROUND: Following the 2018 mass shooting at Marjory Stoneman Douglas High School in Parkland, Florida, there was a dramatic increase in media coverage of extreme risk protection orders (ERPOs) and in state policy proposals for ERPO laws. This study documents the frequency of news coverage of ERPOs throughout 2018 and examines the narratives used by media outlets to describe this risk-based firearm policy. METHODS: Using a mixed-method descriptive design, we examine the frequency of national news media coverage of ERPO legislation in 2018, before and after the Parkland shooting, and analyze the content of news articles related to a sample of states that considered ERPO legislation after the shooting. RESULTS: We find a sharp increase in the frequency of articles related to ERPOs following the Parkland shooting and smaller increases in coverage surrounding ERPO policy proposals and other public mass shootings that year. Nearly three-quarters of articles in our content analysis mentioned the Parkland shooting. The news media often mentioned or quoted politicians compared to other stakeholders, infrequently specified uses for ERPOs (e.g., prevention of mass violence, suicide, or other violence), and rarely included evidence on effectiveness of such policies. More than one-quarter of articles mentioned a mass shooting perpetrator by name, and one-third of articles used the term "gun control." CONCLUSIONS: This study describes the emerging public discourse, as informed by media messaging and framing, on ERPOs as states continue to debate and implement these risk-based firearm violence prevention policies.

Risk factors for assaultive reinjury and death following a nonfatal firearm assault injury: A population-based retrospective cohort study.

Individuals with a firearm injury are at high risk of subsequent firearm victimization, but characteristics associated with sustaining recurrent firearm injuries are not well understood. In this retrospective cohort study, we sought to quantify the hazards of sustaining subsequent assaultive firearm injuries among people with an initial firearm assault injury and to identify characteristics associated with recurrent victimization. Using hospital discharge, emergency department, and mortality records, we identified and followed all individuals aged ≥15 years with a nonfatal firearm assault injury resulting in an emergency department visit or hospital admission in California, 2005-2013. We model transitions from one injury to the next and from injury to death, accounting for event history, covariates, and competing risks using multistate models. 29,156 people had an index nonfatal firearm assault injury. Among individuals with 1 such injury, 3.1% had additional nonfatal firearm assault injuries and 1.0% subsequently died from firearm homicide. Among individuals with 2+ nonfatal firearm assaults, 2.0% died from firearm homicide. The estimated transition probability for 1 to 2+ nonfatal injuries reached 10% by 8.5 years post-index injury. The rate of subsequent nonfatal firearm assault injury was highest among men (hazard ratio [HR]: 3.87; 95% confidence interval [CI]: 2.63-5.69) and Blacks (vs. whites) (HR: 2.69; 95% CI: 1.99-3.64). Identification of additional risk markers will require more detailed individual-level data; nonetheless, this study supports the generalizability of findings from smaller studies, provides broad guidance for allocating scarce resources, and suggests that interventions on root causes of violence disparities may have downstream effects on recurrence.

Extreme Risk Protection Orders Intended to Prevent Mass Shootings: A Case Series.

Urgent, individualized interventions to reduce firearm access, such as extreme risk protection orders (ERPOs, colloquially known as "red flag" orders), provide a rapid, focused response when risk for imminent firearm violence is high. Studies to date suggest such interventions are most commonly used to prevent suicide and are effective. Authorizing legislation has often been enacted after public mass shootings but, to our knowledge, there have been only 2 reported cases of ERPO use in efforts to prevent mass shootings. California enacted the nation's first ERPO statute, which took effect in January 2016. The authors are evaluating that statute's implementation and effectiveness and are seeking to obtain court records for all 414 cases occurring in 2016 to 2018. Based on 159 records received thus far, this article presents an aggregate summary and individual histories for a preliminary series of 21 cases in which ERPOs were used in efforts to prevent mass shootings. Most subjects were male and non-Hispanic white; the mean age was 35 years. Most subjects made explicit threats and owned firearms. Four cases arose primarily in relation to medical or mental health conditions, and such conditions were noted in 4 others. Fifty-two firearms were recovered. As of early August 2019, none of the threatened shootings had occurred, and no other homicides or suicides by persons subject to the orders were identified. It is impossible to know whether violence would have occurred had ERPOs not been issued, and the authors make no claim of a causal relationship. Nonetheless, the cases suggest that this urgent, individualized intervention can play a role in efforts to prevent mass shootings, in health care settings and elsewhere. Further evaluation would be helpful.

Limiting Alcohol Outlet Density to Prevent Alcohol Use and Violence: Estimating Policy Interventions Through Agent-Based Modeling.

Increasing alcohol outlet density is well-documented to be associated with increased alcohol use and problems, leading to the policy recommendation that limiting outlet density will decrease alcohol problems. Yet few studies of decreasing problematic outlets and outlet density have been conducted. We estimated the association between closing alcohol outlets and alcohol use and alcohol-related violence, using an agent-based model of the adult population in New York City. The model was calibrated according to the empirical distribution of the parameters across the city's population, including the density of on- and off-premise alcohol outlets. Interventions capped the alcohol outlet distribution at the 90th to the 50th percentiles of the New York City density, and closed 5% to 25% of outlets with the highest levels of violence. Capping density led to a lower population of light drinkers (42.2% at baseline vs. 38.1% at the 50th percentile), while heavy drinking increased slightly (12.0% at baseline vs. 12.5% at the 50th percentile). Alcohol-related homicides and nonfatal violence remained unchanged. Closing the most violent outlets was not associated with changes in alcohol use or related problems. Results suggest that focusing solely on closing alcohol outlets might not be an effective strategy to reduce alcohol-related problems.

Psychiatric Disorders and Gun Carrying among Adolescents in the United States.

OBJECTIVES: To estimate associations between psychiatric disorders and gun carrying among adolescents and to estimate the total number of adolescents in the US who have psychiatric disorders and report carrying guns. STUDY DESIGN: We used cross-sectional data from the National Comorbidity Survey - Adolescent Supplement, a nationally representative sample of adolescents age 13-18 years (N = 10 123; response rate = 75.6%). Psychiatric disorders were assessed using the Composite International Diagnostic Interview. Gun carrying in the 30 days prior to the interview was assessed by self-report. We used multivariable Poisson regression to test for associations. RESULTS: The analytic sample included 10 112 adolescents, 2.4% of whom reported carrying a gun in the prior 30 days. The prevalence of gun carrying was greater among adolescents with conduct disorder (adjusted prevalence ratio [APR] = 1.88, 95% CI 1.38, 2.57), drug use disorders (APR = 1.91, 95% CI 1.05, 3.45), and specific phobias (APR = 1.54, 95% CI 1.07, 2.22) compared with adolescents without these disorders. We estimated that 1.1% (95% CI 0.77, 1.48) of adolescents with a disorder associated with self- or other-directed violence also carry guns. Nationally, that is approximately 272 000 adolescents with both risk factors. CONCLUSIONS: Specific psychiatric disorders are associated with an increased risk of gun carrying among adolescents, but the vast majority of adolescents with psychiatric disorders did not report gun carrying. Targeted efforts to assess access to and use of firearms in mental healthcare and other clinical settings are important, as are efforts to identify population approaches to prevention.

The Role of Maternal Adverse Childhood Experiences and Race in Intergenerational High-Risk Smoking Behaviors.

INTRODUCTION: A history of adversity in childhood is associated with cigarette smoking in adulthood, but there is less evidence for prenatal and next-generation offspring smoking. We investigated the association between maternal history of childhood adversity, pregnancy smoking, and early initiation of smoking in offspring, overall and by maternal race/ethnicity. METHODS: Data on maternal childhood exposure to physical abuse, household alcohol abuse, and household mental illness, prenatal smoking behaviors, and offspring age of smoking initiation were analyzed from the US National Longitudinal Survey of Youth 1979 (NLSY79, n = 2999 mothers) and the NLSY79 Children and Young Adults Survey (NLSYCYA, n = 6596 children). Adjusted risk ratios were estimated using log-linear regression models. We assessed multiplicative interaction by race/ethnicity for all associations and a three-way interaction by maternal exposure to adversity and race/ethnicity for the association between prenatal and child smoking. RESULTS: Maternal exposure to childhood physical abuse was significantly associated with 39% and 20% increased risks of prenatal smoking and child smoking, respectively. Household alcohol abuse was associated with significantly increased risks of 20% for prenatal smoking and 17% for child smoking. The prenatal smoking-child smoking relationship was modified by maternal exposure to household alcohol abuse and race. There were increased risks for Hispanic and white/other mothers as compared to the lowest risk group: black mothers who did not experience childhood household alcohol abuse. CONCLUSIONS: Mothers in this national sample who experienced adversity in childhood are more likely to smoke during pregnancy and their offspring are more likely to initiate smoking before age 18. Findings varied by type of adversity and race/ethnicity. IMPLICATIONS: These findings support the importance of a life-course approach to understanding prenatal and intergenerational smoking, and suggest that maternal early-life history is a potentially important risk factor that could be targeted with screening and interventions to reduce smoking in pregnant women and their children.

Firearm Ownership and Support for Political Violence in the United States.

Importance: Little is known about support for and willingness to engage in political violence in the United States. Such violence would likely involve firearms. Objective: To evaluate whether firearm owners' and nonowners' support for political violence differs and whether support among owners varies by type of firearms owned, recency of purchase, and frequency of carrying a loaded firearm in public. Design, Setting, and Participants: This cross-sectional nationally representative survey study was conducted from May 13 to June 2, 2022, among US adult members of the Ipsos KnowledgePanel, including an oversample of firearm owners. Exposure: Firearm ownership vs nonownership. Main Outcomes and Measures: Main outcomes concern (1) support for political violence, in general and to advance specific political objectives; (2) personal willingness to engage in political violence, by severity of violence and target population; and (3) perceived likelihood of firearm use in political violence. Outcomes are expressed as weighted proportions and adjusted prevalence differences, with P values adjusted for the false-discovery rate and reported as q values. Results: The analytic sample comprised 12 851 respondents: 5820 (45.3%) firearm owners, 6132 (47.7%) nonowners without firearms at home, and 899 (7.0%) nonowners with firearms at home. After weighting, 51.0% (95% CI, 49.9%-52.1%) were female, 8.5% (95% CI, 7.5%-9.5%) Hispanic, 9.1% (95% CI, 8.1%-10.2%) non-Hispanic Black, and 62.6% (95% CI, 61.5%-63.8%) non-Hispanic White; the mean (SD) age was 48.5 (18.0) years. Owners were more likely than nonowners without firearms at home to consider violence usually or always justified to advance at least 1 of 17 specific political objectives (owners: 38.8%; 95% CI, 37.3%-40.4%; nonowners: 29.8%; 95% CI, 28.5%-31.2%; adjusted difference, 6.5 percentage points; 95% CI, 4.5-9.3 percentage points; q < .001) but were not more willing to engage in political violence. Recent purchasers, owners who always or nearly always carry loaded firearms in public, and to a lesser extent, owners of assault-type rifles were more supportive of and willing to engage in political violence than other subgroups of firearm owners. Conclusions and Relevance: In this study of support for political violence in the United States, differences between firearm owners and nonowners without firearms at home were small to moderate when present. Differences were greater among subsets of owners than between owners and nonowners. These findings can guide risk-based prevention efforts.

Law Enforcement Officer Knowledge of, Attitudes Toward, and Willingness to Use Extreme Risk Protection Orders.

Importance: Understanding knowledge of, attitudes toward, and willingness to use extreme risk protection order (ERPO) laws among law enforcement officers (LEOs) can inform efforts to improve implementation of this underused firearm violence prevention strategy. Objective: To characterize LEOs' knowledge of, attitudes toward, and willingness to use ERPOs across a range of scenarios. Design, Setting, and Participants: A cross-sectional online survey, fielded from April 5 to August 30, 2021, was conducted in all 19 states and the District of Columbia with an ERPO law in 2021. A nonprobability sample of active-duty LEOs was used. Exposure: Being a LEO in a state with an ERPO law. Main Outcomes and Measures: Survey participants answered questions about their familiarity with and opinions on ERPO laws, as well as whether they would agree with using an ERPO in a variety of specific case scenarios. The analysis included an exploration of whether within-scenario differences, such as ERPO respondent race or gender, affected agreement by randomly assigning survey participants to 1 of 2 versions of each scenario. Results: A total of 600 eligible individuals started the survey, and 283 survey participants were included in the analysis. The analytic sample consisted mostly of cisgender men (85.2%) and non-Hispanic White (71.4%) LEOs. Participants represented 14 states and the District of Columbia, with 53.7% living in California. Most participants (81.3%) were very or somewhat familiar with ERPO laws and 56.2% had received ERPO training. Opinions about ERPO laws were generally favorable but varied by self-identified political ideology. Across all scenarios, most participants supported using an ERPO; however, support was highest in cases involving intimate partner violence (71.4%-78.6%) and lowest in cases involving suicidality (54.2%-73.3%). Across all scenarios, LEOs with ERPO training or experience were substantially more likely to agree with using ERPOs than those without. None of the randomly assigned within-scenario differences were associated with differences in ERPO support. Conclusions and Relevance: In this survey study of LEOs in states with ERPO laws, many officers had not received training on their use. Additionally, while conservative political ideology was associated with less favorable views of ERPOs, training and experience with ERPOs was associated with greater support for their use across a range of scenarios. These findings suggest that LEO training on ERPOs may promote their uptake and improve implementation.

Changes in self-harm and suicide in California from 2017-2021: a population-based study.

Background : Self-harm and suicide are major public health problems with immediate and long-term effects on individuals, families, and communities. In 2020 and 2021, stressors wrought by the COVID-19 pandemic, stay-at-home mandates, economic turmoil, social unrest, and growing inequality likely modified risk for self-harm. The coinciding surge in firearm purchasing may have increased risk for firearm suicide. In this study, we examined changes in counts and rates of fatal and nonfatal intentional self-harm in California across sociodemographic groups during the first two years of the COVID-19 pandemic relative to prior years. Methods: We used California-wide death data and University of California (UC)-wide hospital data to summarize fatal and nonfatal instances of intentional self-harm across race/ethnicity, age, education, gender, region, and method of harm. We compared case counts and rates in 2020 and 2021 with 2017-2019 averages. Results : Suicide decreased overall in 2020 (4123 deaths; 10.5 per 100,000) and 2021 (4104; 10.4 per 100,000), compared to pre-pandemic (4484; 11.4 per 100,000). The decrease in counts was driven largely by males, white, and middle-aged Californians. Conversely, Black Californians and young people (age 10-19) experienced increased burden and rates of suicide. Firearm suicide also decreased following the onset of the pandemic, but relatively less than overall suicide; as a result, the proportion of suicides that involved a firearm increased (from 36.1% pre-pandemic to 37.6% in 2020 and 38.1% in 2021). Females, people aged 20-29, and Black Californians had the largest increase in the likelihood of using a firearm in suicide following the onset of the pandemic. Counts and rates of nonfatal, intentional self-harm in UC hospitals increased in 2020 (2160; 30.7 per 100,000) and 2021 (2175; 30.9 per 100,000) compared to pre-pandemic (2083; 29.6 per 100,000), especially among young people (age 10-19), females, and Hispanic Californians. Conclusions : The COVID-19 pandemic and co-occurring stressors coincided with heterogeneous changes in risk of self-harm and suicide across the California population. Marginalized racial groups, females, and younger people experienced increased risk for self-harm, particularly involving a firearm. Public health intervention and policy action are necessary to prevent fatal and nonfatal self-harm injuries and reduce related inequities.

Changes in suicide in California from 2017 to 2021: a population-based study.

BACKGROUND: Suicide is a major public health problem with immediate and long-term effects on individuals, families, and communities. In 2020 and 2021, stressors wrought by the COVID-19 pandemic, stay-at-home mandates, economic turmoil, social unrest, and growing inequality likely modified risk for self-harm. The coinciding surge in firearm purchasing may have increased risk for firearm suicide. In this study, we examined changes in counts and rates of suicide in California across sociodemographic groups during the first two years of the COVID-19 pandemic relative to prior years. METHODS: We used California-wide death data to summarize suicide and firearm suicide across race/ethnicity, age, education, gender, and urbanicity. We compared case counts and rates in 2020 and 2021 with 2017-2019 averages. RESULTS: Suicide decreased overall in 2020 (4123 deaths; 10.5 per 100,000) and 2021 (4104; 10.4 per 100,000), compared to pre-pandemic (4484; 11.4 per 100,000). The decrease in counts was driven largely by males, white, and middle-aged Californians. Conversely, Black Californians and young people (age 10 to 19) experienced increased burden and rates of suicide. Firearm suicide also decreased following the onset of the pandemic, but relatively less than overall suicide; as a result, the proportion of suicides that involved a firearm increased (from 36.1% pre-pandemic to 37.6% in 2020 and 38.1% in 2021). Females, people aged 20 to 29, and Black Californians had the largest increase in the likelihood of using a firearm in suicide following the onset of the pandemic. The proportion of suicides that involved a firearm in 2020 and 2021 decreased in rural areas compared to prior years, while there were modest increases in urban areas. CONCLUSIONS: The COVID-19 pandemic and co-occurring stressors coincided with heterogeneous changes in risk of suicide across the California population. Marginalized racial groups and younger people experienced increased risk for suicide, particularly involving a firearm. Public health intervention and policy action are necessary to prevent fatal self-harm injuries and reduce related inequities.