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. 2024 Aug 5;19(8):e0290138. doi: 10.1371/journal.pone.0290138

Fallacy of attributing the U.S. firearm mortality epidemic to mental health

Archie Bleyer 1,2,*, Stuart E Siegel 3, Jaime Estrada 4, Charles R Thomas Jr 5
Editor: Claudio Alberto Dávila-Cervantes6
PMCID: PMC11299823  PMID: 39102407

Abstract

Background

Annual global data on mental disorders prevalence and firearm death rates for 2000–2019, enables the U.S. to be compared with comparable counties for these metrics.

Methods

The Institute for Health Metrics and Evaluation (IHME) Global Health Burden data were used to compare the prevalence of mental disorders with overall, homicide and suicide firearm death rates including homicides and suicides, in high sociodemographic (SDI) countries.

Results

Overall and in none of the nine major categories of mental disorders did the U.S. have a statistically-significant higher rate than any of 40 other high SDI countries during 2019, the last year of available data. During the same year, the U.S. had a statistically-significant higher rate of all deaths, homicides, and suicides by firearm (all p<<0.001) than all other 40 high SDI countries. Suicides accounted for most of the firearm death rate differences between the U.S. and other high SDI countries, and yet the prevalence of mental health disorders associated with suicide were not significantly difference between the U.S. and other high SDI countries.

Conclusion

Mental disorder prevalence in the U.S. is similar in all major categories to its 40 comparable sociodemographic countries, including mental health disorders primarily associated with suicide. It cannot therefore explain the country’s strikingly higher firearm death rate, including suicide. Reducing firearm prevalence, which is correlated with the country’s firearm death rate, is a logical solution that has been applied by other countries.

Introduction

The firearm injury and death rates in the U.S. are at an all-time high and continuing to increase. Its gun lobby blames the crisis on citizens with mental health disorders and not on firearm prevalence. The National Rifle Association, which arguably wields far greater influence over national firearms policy than does public opinion [1], lays the blame for mass shootings on untreated mental illness—rather than unregulated guns—and proposed the creation of a national database of persons with mental illness [2]. Indeed, the NRA’s mantra is “The only guy that can stop a bad guy with a gun is a good guy with a gun" [3]. Recent availability of data on firearm homicides, suicides and unintentional deaths and on mental disorders in the world’s countries and territories [4] allows testing of the hypothesis that the country’s mental health is a primary reason for its firearm mortality crisis.

Methods

The mean and 95% confidence intervals (C.I.) of mental health disorders prevalence were obtained for the U.S. and other high sociodemographic index (SDI) [5] countries from the Institute of Health Metrics and Evaluation (IHME) Global Health Burden resource [4]. For each of nine mental health disorders provided by IHME, the U.S. was compared with each of 40 other high SDI countries for overall firearm deaths, firearm homicides, and firearm suicides. Annual firearm death rate data in the U.S. was obtained from the Centers for Disease Control and Prevention Web-based Injury Statistics Query, Reporting and WONDER Systems [6,7]. U.S. data were available until 2021 whereas IHME SDI country data were not available after 2019. The Joinpoint Regression Program, version 5.0.1-April 2023 [8] and its constant variance option, was used to identify mortality trends and when they occurred. Joinpoint-derived p-values in the figures are designated in the text as <<0.001 if several logs <0.001.

Results

Mental disorder prevalence

In none of the nine major categories of mental disorders provided by IHME did the U.S. have a statistically-significantly higher rate than any of the other high SDI countries during 2019, the last year of available data (Fig 1). In rank order of the 41 high SDI countries, the U.S. was 5th in all mental health disorders and 12th, 2nd, 4th, 32nd, 35th, 1st, 4th, 21st, and 9th in anxiety, depression, attention deficit/hyperactive, bipolar, conduct, schizophrenia, autism, eating, and idiopathic developmental intellectual disability disorders, respectively (Fig 1).

Fig 1. Mean & 95% C.I. of mental disorders prevalence in 41 high sociodemographic index (SDI) countries, 2019, by disorder type.

Fig 1

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Upper panel: Anxiety, Depression, Attention Deficit/Hyperactivity Disorders, and Bipolar Disorders. Lower panel: Conduct Disorders, Schizophrenia, Autism Disorders, and Other Mental Disorders. *SDI- Sociodemographic Index. **ADHD—Attention Deficit/Hyperactivity Disorders. Data Source: IHME [4].

Firearm death rate

During the last two decades, the U.S. had rate increases since 2006 for firearm suicides and since 2010 for all firearm deaths and firearm homicides (all p<<0.001) (Fig 2). In contrast, the average rate in other high SDI countries decreased during 2000–2019 for all firearm deaths, firearm suicides and firearm homicides (p = 0.003 for all firearm deaths) (Fig 2).

Fig 2. Joinpoint/AAPC* analysis of annual overall firearm death, homicide and suicide rates, 2000–2019, U.S and other high SDI countries.

Fig 2

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*AAPC–Average Annual Percent Change. Data Sources: CDC WISQARS [6] for U.S.; IHME [4] for other high SDI countries.

In both the U.S. and other high SDI countries the majority of firearm deaths during 2010–2019 were suicides (59% and 62%, respectively) (Fig 2). In comparison with suicides by specified methods other than firearm, the U.S. had a greater increase in firearm suicides than did other high SDI countries (Fig 3 left panels). For every year during 2000–2019, the percentage of all suicides that occurred by firearm was >50% in the U.S. and <10% on average in other high SDI countries. Each of the other high SDI countries had decreases in the firearm suicide rate, especially Canada, Switzerland, Finland, France, France, Belgium, Slovenia, Norway, Estonia and Latvia and only San Marino and Monaco did not have substantial decreases from relatively higher rates (Fig 3 upper right panel). For non-firearm suicide, the U.S. had an increasing rate during 2000–2019, whereas the rate significantly decreased overall in high SDI countries and only Guam had an increase among all other high SDI countries (Fig 3 lower left panel). As of 2019, all but 8 of the other 40 high SDI countries had a greater rate than the U.S. (Fig 3 lower right panel)

Fig 3. Annual suicide rate by firearm (upper panel) and by method other than by firearm (lower panel), U.S. 2000–2021 and other evaluable high SDI countries 2000–2019.

Fig 3

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Data Sources: CDC WONDER [7] for U.S., IHME [4] for other high SDI countries.

In 2019, the U.S. had a statistically-significant higher rate of overall firearm deaths, firearm suicides, and firearm homicides than each of the other 40 high SDI countries (all 120 p-value differences <0.001) (Fig 4). Compared with the average of all other high SDI countries, the U.S. rate was 10.1 times higher for overall firearm, 7.9 times higher for firearm suicide, and 18.6 times greater for firearm homicides.

Fig 4. Firearm death rates, high SDI countries, 2019, by country and type of firearm death.

Fig 4

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Data Source: IHME [4].

During the last decade, the age-adjusted overall firearm death rate increased statistically significantly among the high SDI countries in only the U.S. (AAPC = 2.2, p<0.001) and, at a much lower rate, San Marino (AAPC = 0.5, p<0.001) (S1 Fig). Of the 39 other high SDI countries, 33 had a statistically-significant decrease and 6 had no significant change (S1 Fig).

Comparisons of firearm death rate and mental health disorder prevalence

Of 150 comparisons of overall, homicide and suicide firearm death trends with mental health disorder trends evaluated for 2000-2019 eras in the U.S., only 10 were either strongly or highly correlated (Pearson correlation coefficients >0.80) (Table 1). Firearm suicide was correlated with conduct disorders for eras during 2000-2019, with autism disorders during 2005-2019, and attention deficit and eating disorders during 2015–2019, and these correlations were reflected in the overall firearm death correlations (Table 1). None of the firearm homicide comparisons were correlated (Table 1).

Table 1. Pearson correlation coefficients (r) of comparisons of age-adjusted firearm death rates and age-adjusted prevalence of mental disorders, 1990–2019, by type of firearm death, mental disorder, and Era, U.S. Bolded values: r > 0.80.

  Era: 1990–2019 1995–2019 2000–2019 2005–2019 2010–2019 2015–2019
    All Firearm Death Rate
All Mental Disorders -0.83 -0.65 -0.63 -0.66 -0.50 0.35
  Anxiety Disorders -0.63 -0.55 -0.58 -0.61 -0.42 0.31
  Depressive Disorders -0.92 -0.93 -0.89 -0.89 -0.86 -0.90
  ADHD* -0.82 -0.41 0.50 0.49 0.69 0.95
  Bipolar Disorder 0.64 0.14 -0.67 -0.75 -0.96 -0.93
  Conduct Disorder 0.07 0.31 0.84 0.83 0.78 -0.77
  Schizophrenia -0.61 -0.66 -0.92 -0.94 -0.95 -0.97
  Autism Disorders** -0.35 0.01 0.55 0.50 0.77 0.61
  Eating Disorders -0.49 0.04 -0.78 -0.77 -0.67 0.94
  Intellectual Disability*** 0.49 -0.36 -0.64 -0.67 -0.86 -0.61
    Firearm Homicide Rate
All Mental Disorders -0.75 -0.45 -0.25 -0.21 -0.44 0.28
  Anxiety Disorders -0.53 -0.34 -0.20 -0.14 -0.37 0.25
  Depressive Disorders -0.88 -0.77 -0.55 -0.55 -0.80 -0.73
  ADHD* -0.81 -0.40 0.63 0.66 0.68 0.75
  Bipolar Disorder 0.71 0.35 -0.25 -0.23 -0.90 -0.69
  Conduct Disorder -0.07 0.03 0.43 0.42 0.72 -0.57
  Schizophrenia -0.47 -0.40 -0.56 -0.59 -0.89 -0.76
  Autism Disorders** -0.47 -0.27 0.05 -0.07 0.72 0.44
  Eating Disorders -0.36 0.28 -0.39 -0.38 -0.61 0.70
  Intellectual Disability*** 0.59 -0.09 -0.19 -0.13 -0.80 -0.45
    Firearm Suicide Rate
All Mental Disorders -0.89 -0.79 -0.78 -0.84 -0.57 0.33
  Anxiety Disorders -0.77 -0.73 -0.74 -0.83 -0.49 0.29
  Depressive Disorders -0.85 -0.91 -0.90 -0.90 -0.90 -0.90
  ADHD* -0.70 -0.23 0.27 0.19 0.66 0.95
  Bipolar Disorder 0.36 -0.24 -0.83 -0.96 -0.99 -0.99
  Conduct Disorder 0.40 0.64 0.93 0.92 0.84 -0.80
  Schizophrenia -0.81 -0.85 -0.92 -0.95 -0.98 -0.97
  Autism Disorders** -0.01 0.43 0.79 0.83 0.77 0.64
  Eating Disorders -0.70 -0.36 -0.86 -0.86 -0.74 0.98
  Intellectual Disability*** 0.18 -0.66 -0.84 -0.92 -0.87 -0.62
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* ADHD -Attention-deficit/hyperactivity disorder.

** Autism spectrum disorders.

*** Idiopathic developmental intellectual disability.

Discussion

Our results indicate that the U.S. has a similar prevalence of mental disorders to that in 40 other high SDI countries. In 2019, the U.S. had an overall mental health disorder ranking of 5th and average ranking of 13 among the nine categories of mental disorders among the 40 high SDI countries. Its firearm death rate ranking, however, is by far in 1st place, 10-fold greater in 2019 than the average of all other high SDI countries for all firearm deaths and 19-fold for firearm homicides. Suicides accounted for more of the firearm death rate differences between the U.S. and other high SDI countries than homicides, and yet the prevalence of mental health disorders associated with suicide such as depression, anxiety, schizophrenia, bipolar and conduct disorders, were not significantly difference between the U.S. and other high SDI countries. Our results include lack of correlation of the U.S. firearm mortality trends with its mental disorder prevalence trends, with possible exceptions of conduct, autism, attention deficit and eating disorders correlated only with firearm suicide and limited to certain eras since 2000.

The difference between the U.S. and all other high SDI countries cannot be explained by differences in mental disorder prevalence. Yet, a significant proportion of the U.S. populace attributes its firearm mortality and injury epidemic to inadequate care of its mentally-disabled population. A decade ago, a public opinion poll found that a majority of Americans across the political spectrum favored “increasing government spending to improve mental health screening and treatment as a strategy to prevent gun violence” [9]. As of last year, a national poll found that nearly half of respondents believe mass shootings are more common in the U.S. than in other countries because of mental health issues, and that a majority of both Republicans and Democrats respondents believe better mental health screening and treatment would be one of the most effective ways to prevent mass shootings [10]. Mental health experts and consumer advocates thus face the difficult prospect of debunking the public perception that “the mentally ill are dangerous” [11].

Multiple studies have correlated the U.S. firearm mortality and injury rates with firearm prevalence as estimated by the firearm background check rate [12–16], the proportion of suicides by firearm [13,16–25], surveys [26–29], and the proportion of the world’s firearms in civilian hands [30]. As reported recently in the American Association of Medical Colleges News, focusing on mental illness as the cause of firearm violence diverts attention from the larger problem of gun violence in the U.S., and distracts from the real issue when it comes to guns and mental health: suicide [31]. The strikingly higher suicide rate in the U.S. has been attributed primarily to access of suicidal persons to firearms that exists in few in any other countries. Other high SDI countries have decreased firearm prevalence and subsequently reduced their firearm death rate [32], including Australia [33], Canada [34,35], New Zealand [36], Switzerland [27,37], and Israel [37] (S2 Fig). According to a comparison of Canada with the U.S., 1 in 4 U.S. suicide fatalities could be averted if the U.S. had the same suicide rates as in Canada and its lower firearm ownership rates [38].

Although the primary limitation of this study is its ecologic nature, case control and cohort studies support firearm access per se as a causal factor of firearm mortality and not mental health per se. In the U.S., higher rates of firearm ownership at the state level have been shown to be strongly associated with higher rates of firearm suicide but not with non-firearm suicide or gun ownership level [39]. The authors concluded that firearm ownership rates independent of underlying rates of suicidal behavior largely determine variations in suicide mortality across the 50 states [39]. In the U.S., a nationally representative study of 10,123 13–18 year-olds estimated that their risk of suicide was increased 3–4 times if they had lived in homes with a firearm compared with if they had not [40]. An analysis of four U.S. studies did not suggest any other confounders that explain the association between firearms and suicide [41].

Other examples have evidenced that suicide rates can be substantially reduced without targeting underlying mental health or suicidality. The success in preventing suicides in Sri Lanka by reducing access to the most highly toxic pesticides is, as the authors conclude, “one of the strongest empirical arguments” and supports ‘household firearm ownership as a consistent strong predictor of suicide risk in studies that examined individual-level data” [42].

None of this minimizes the need for the U.S. to provide more support, especially research and including funding, for its overall mental health. As our study shows, the U.S. is also among high SDI countries with the greatest prevalence for depression, schizophrenia, attention deficit/hyperactivity and autism disorders. The trends in the U.S. of firearm death rates do not correlate, however, with either its overall mental disorder prevalence trend or with any of the major mental disorder types except conduct disorder. The relative ranking among the high SDI counties could be due in part to the psychosocial impact of the firearm injury and mortality epidemic in the U.S., rather than to the reverse of mental disorder prevalence causing the country’s firearm crisis.

With the onset of the Covid-19 pandemic in 2020, the U.S. has had acceleration of firearm purchases [43] and firearm deaths [44]. As recently reported in PLOS-ONE, pandemic gun buyers surveyed exhibited more mental health characteristic, including suicidality, depression, anxiety, and substance use than non-gun owners and pre-pandemic gun owners [45]. As of 2019 and the prior two decades, however, mental health disorder rates in the U.S. do not explain the country’s firearm mortality crisis.

In summary, mental disorder prevalence in the U.S. is similar in all major categories to its 40 comparable sociodemographic countries, including mental health disorders primarily associated with suicide. The country’s firearm crisis should not be blamed on lack of mental healthcare. Reducing firearm prevalence, which is correlated with the country’s firearm death rate, is a logical solution that has been applied successfully by other countries.

Supporting information

S1 Fig

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pone.0290138.s001.pdf (1.2MB, pdf)
S2 Fig

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pone.0290138.s002.pdf (887.9KB, pdf)
S1 File

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pone.0290138.s003.pdf (124.2KB, pdf)
S2 File

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pone.0290138.s004.pdf (102.3KB, pdf)
S3 File

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pone.0290138.s005.pdf (129.5KB, pdf)
S4 File

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pone.0290138.s006.pdf (112.8KB, pdf)
S5 File

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pone.0290138.s007.pdf (115.8KB, pdf)

Data Availability

The data and associated analyses are publicly available at https://www.comedsoc.org/2024/02/15/u-s-mental-health-and-firearm-mortality-epidemic/.

Funding Statement

The author(s) received no specific funding for this work.

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  • 44.Lundstrom EW, Groth CP, Harrison JE, Hendricks B, Smith GS. Excess US firearm mortality during the COVID-19 pandemic stratified by intent and urbanization. JAMA Netw Open. 2023. Jul 3;6(7):e2323392. doi: 10.1001/jamanetworkopen.2023.23392 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Hicks BM, Vitro C, Johnson E, et al. (2023) Who bought a gun during the COVID-19 pandemic in the United States?: Associations with QAnon beliefs, right-wing political attitudes, intimate partner violence, antisocial behavior, suicidality, and mental health and substance use problems. PLoS ONE 18(8): e0290770. doi: 10.1371/journal.pone.0290770 [DOI] [PMC free article] [PubMed] [Google Scholar]

Decision Letter 0

Claudio Alberto Dávila-Cervantes

1 Dec 2023

PONE-D-23-22215Fallacy of Attributing the U.S. Firearm Mortality Epidemic to Mental HealthPLOS ONE

Dear Dr. Bleyer,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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The authors must focus on integrating more peer-reviewed literature in the introduction and discussion.

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

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Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors deserve my sincere congratulations. It has been quite some time since I reviewed such a good paper.

The introduction is straightforward , the hypothesis is highly relevant, the data source is reliable, the statistical analysis is simple but efficient, and the discussion is clear and concise.

Reviewer #2: The manuscript is sound and addresses an important topic. Statistical analysis is also valid. However, it lacks a literature review on the topic. Authors should also rephrase some sentences to incorporate passive voice only.

Reviewer #3: The manuscript under review, “Fallacy of Attributing the U.S. Firearm Mortality Epidemic to Mental Health” is a cogent empirical essay that underscores an observation in need of reinforcement. Namely, that mental disorder prevalence in the U.S. is similar in all major categories to its 40 comparable sociodemographic countries and cannot explain the U.S. firearm crisis. None of this minimizes the need for the U.S. to support overall mental health, as the authors take care to note.

The paper could be strengthened substantially by integrating well-established research in the peer-reviewed literature in the introduction and discussion, such as studies that mirror what the authors present at the international level using within state variation in the US and bias analyses of existing case control studies on the relation between guns and suicide . The straw man use of the NRA detracts from an otherwise sober and thoughtfully written manuscript. Better to cite prior work that has built the case to date and to which this paper adds value.

Some of these papers include:

Azrael D and Miller M. Reducing Access to Lethal Means. A Review of the Evidence Base. Chapter XXVI. The International Handbook of Suicide Prevention, Second Edition. Edited by Rory C. O’Connor and Jane Pirkis. Published 2016 by John Wiley & Sons, Ltd.. Baffins Lane, Chichester, West Sussex PO19 1UD, England.

Miller M, Swanson S, Azrael D. Are We Missing Something Pertinent? A Bias Analysis of Unmeasured Confounding in the Firearm-Suicide Literature. Epidemiol Rev (2016) 38 (1): 62-69.doi: 10.1093/epirev/mxv011.

Swanson S, Eyllon M, Sheu Y, Miller M. Firearm access and adolescent suicide risk: Toward a clearer understanding of effect size. Injury Prevention. Published Online First: 14 May 2020. doi: 10.1136/injuryprev-2019-043605.

Miller M, Barber C, Azrael D, White R. Firearms and suicide in the United States: is risk independent of underlying suicidal behavior? Am J Epidemiol 2013 Sep 15;178(6):946-55. doi: 10.1093/aje/kwt197. Epub 2013 Aug 23.

In the discussion the authors focus only on the ecologic literature when making the case that firearms causally contribute to suicide rates. The argument could be strengthened by also referring to the individual-level case control and cohort studies that exist. I’m not sure that the argument they make when evoking reviews of the effect of legislation advances their argument. The authors should review those paragraphs and ask themselves what if anything does this text support of relevance to their important but modest point.

**********

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Reviewer #3: No

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PLoS One. 2024 Aug 5;19(8):e0290138. doi: 10.1371/journal.pone.0290138.r002

Author response to Decision Letter 0

10 Dec 2023

Revision Summary

The authors completely agreed with the recommendations. In general we added discussion of other relevant reports in the medical literature, four of which were selected, and removed the discussion on legislative impact and its 3 references). In total the manuscript was actually thus shortened, from 3,375 to 3,378 text words, and the number of references (45) being the same. Also, the figures and supporting information are being separately submitted as tiff files.

Reviewer #1:

The authors deserve my sincere congratulations. It has been quite some time since I reviewed such a good paper. The introduction is straightforward , the hypothesis is highly relevant, the data source is reliable, the statistical analysis is simple but efficient, and the discussion is clear and concise.

Reviewer #2:

The manuscript is sound and addresses an important topic. Statistical analysis is also valid. However, it lacks a literature review on the topic.

As also recommended by Reviewer #3, a literature review has been added:

“Although the primary limitation of this study is its ecologic nature, case control and cohort studies support firearm access per se as a causal factor of firearm mortality and not mental health per se. In the U.S., higher rates of firearm ownership at the state level have been shown to be strongly associated with higher rates of firearm suicide but not with non-firearm suicide or gun ownership level.[New reference39] The authors concluded that firearm ownership rates independent of underlying rates of suicidal behavior largely determine variations in suicide mortality across the 50 states.[New reference 39] In the U.S., a nationally representative study of 10,123 13-18 year-olds estimated that their risk of suicide was increased 3-4 times if they had lived in homes with a firearm compared with if they had not.[New reference 40] An analysis of four U.S. studies did not suggest any other confounders that explain the association between firearms and suicide.[New reference 41]

Other examples have evidenced that suicide rates can be substantially reduced without targeting underlying mental health or suicidality. The success in preventing suicides in Sri Lanka by reducing access to the most highly toxic pesticides is, as the authors conclude, “one of the strongest empirical arguments” and supports ‘household firearm ownership as a consistent strong predictor of suicide risk in studies that examined individual-level data.[New reference 42]”

New References

39. Miller M, Barber C, White RA, Azrael D. Firearms and suicide in the United States: is risk independent of underlying suicidal behavior? Am J Epidemiol. 2013 Sep 15;178(6):946-55. doi:10.1093/aje/kwt197.

40. Swanson SA, Eyllon M, Sheu YH, Miller M. Firearm access and adolescent suicide risk: toward a clearer understanding of effect size. Inj Prev. 2020 May 14;27(3):264–70. doi:10.1136/injuryprev-2019-043605.

41. Miller M, Swanson SA, Azrael D. Are we missing something pertinent? A bias analysis of unmeasured confounding in the firearm-suicide literature. Epidemiol Rev. 2016;38(1):62-9. doi:10.1093/epirev/mxv011.

42: Azrael D and Miller M. Reducing suicide without affecting underlying mental health. Theoretical underpinnings and a review of the evidence base linking the availability of lethal means and suicide. Chapter 35. The International Handbook of Suicide Prevention, 2nd Edition. Edited by Rory C. O’Connor and Jane Pirkis. Published 2016 by John Wiley & Sons, Ltd.. Baffins Lane, Chichester, West Sussex PO19 1UD, England.

Authors should also rephrase some sentences to incorporate passive voice only.

All active voice phrases, which were limited to the Methods section have been rephrased in the passive mode:

“The mean and 95% confidence interval (C.I.) for mental health disorder were obtained for the U.S. and for other high sociodemographic index (SDI)4 countries from the Institute of Health Metrics and Evaluation (IHME) Global Health Burden resource.5 For each of nine mental health disorders provided by IHME, the U.S. was compared with each of 40 other high SDI countries for overall firearm deaths, firearm homicides, and firearm suicides. Annual firearm death rate data in the U.S. was obtained from the Centers for Disease Control and Prevention Web-based Injury Statistics Query, Reporting and WONDER Systems.6,7 U.S. data were available until 2021 whereas IHME SDI country data were not available after 2019. The Joinpoint Regression Program, version 5.0.1-April 20238 and its constant variance option, was used to identify mortality trends and when they occurred. Joinpoint-derived p-values in the figures are designated in the text as <<0.001 if several logs <0.001.”

Reviewer #3:

The manuscript under review, “Fallacy of Attributing the U.S. Firearm Mortality Epidemic to Mental Health” is a cogent empirical essay that underscores an observation in need of reinforcement. Namely, that mental disorder prevalence in the U.S. is similar in all major categories to its 40 comparable sociodemographic countries and cannot explain the U.S. firearm crisis. None of this minimizes the need for the U.S. to support overall mental health, as the authors take care to note.

The paper could be strengthened substantially by integrating well-established research in the peer-reviewed literature in the introduction and discussion, such as studies that mirror what the authors present at the international level using within state variation in the US and bias analyses of existing case control studies on the relation between guns and suicide . The straw man use of the NRA detracts from an otherwise sober and thoughtfully written manuscript. Better to cite prior work that has built the case to date and to which this paper adds value.

Some of these papers include:

Azrael D and Miller M. Reducing Access to Lethal Means. A Review of the Evidence Base. Chapter XXVI. The International Handbook of Suicide Prevention, Second Edition. Edited by Rory C. O’Connor and Jane Pirkis. Published 2016 by John Wiley & Sons, Ltd.. Baffins Lane, Chichester, West Sussex PO19 1UD, England.

This may not be the correct reference information since the authors have the following chapter (#36 and not XXVI) in the 2nd edition of the book: Reducing Suicide Without Affecting Underlying Mental Health. Theoretical Underpinnings and a Review of the Evidence Base Linking the Availability of Lethal Means and Suicide. This chapter is now cited as summarized below.

Miller M, Swanson S, Azrael D. Are We Missing Something Pertinent? A Bias Analysis of Unmeasured Confounding in the Firearm-Suicide Literature. Epidemiol Rev (2016) 38 (1): 62-69.doi: 10.1093/epirev/mxv011.

Swanson S, Eyllon M, Sheu Y, Miller M. Firearm access and adolescent suicide risk: Toward a clearer understanding of effect size. Injury Prevention. Published Online First: 14 May 2020. doi: 10.1136/injuryprev-2019-043605.

Miller M, Barber C, Azrael D, White R. Firearms and suicide in the United States: is risk independent of underlying suicidal behavior? Am J Epidemiol 2013 Sep 15;178(6):946-55. doi: 10.1093/aje/kwt197. Epub 2013 Aug 23.

All four of these references (new #39-42) have been added to the Discussion as summarized below.

In the discussion the authors focus only on the ecologic literature when making the case that firearms causally contribute to suicide rates. The argument could be strengthened by also referring to the individual-level case control and cohort studies that exist.

The references and additional comments in the Discussion:

“Although the primary limitation of this study is its ecologic nature, case control and cohort studies support firearm access per se as a causal factor of firearm mortality and not mental health per se. In the U.S., higher rates of firearm ownership at the state level have been shown to be strongly associated with higher rates of firearm suicide but not with non-firearm suicide or gun ownership level.[New reference 39] The authors concluded that firearm ownership rates independent of underlying rates of suicidal behavior largely determine variations in suicide mortality across the 50 states.[New reference 39] In the U.S., a nationally representative study of 10,123 13-18 year-olds estimated that their risk of suicide was increased 3-4 times if they had lived in homes with a firearm compared with if they had not.[New reference 40] An analysis of four U.S. studies did not suggest any other confounders that explain the association between firearms and suicide.[New reference 41]

Other examples have evidenced that suicide rates can be substantially reduced without targeting underlying mental health or suicidality. The success in preventing suicides in Sri Lanka by reducing access to the most highly toxic pesticides is, as the authors conclude, “one of the strongest empirical arguments” and supports ‘household firearm ownership as a consistent strong predictor of suicide risk in studies that examined individual-level data.[New reference 42]”

New References

39. Miller M, Barber C, White RA, Azrael D. Firearms and suicide in the United States: is risk independent of underlying suicidal behavior? Am J Epidemiol. 2013 Sep 15;178(6):946-55. doi:10.1093/aje/kwt197.

40. Swanson SA, Eyllon M, Sheu YH, Miller M. Firearm access and adolescent suicide risk: toward a clearer understanding of effect size. Inj Prev. 2020 May 14;27(3):264–70. doi:10.1136/injuryprev-2019-043605.

41. Miller M, Swanson SA, Azrael D. Are we missing something pertinent? A bias analysis of unmeasured confounding in the firearm-suicide literature. Epidemiol Rev. 2016;38(1):62-9. doi:10.1093/epirev/mxv011.

42: Azrael D and Miller M. Reducing suicide without affecting underlying mental health. Theoretical underpinnings and a review of the evidence base linking the availability of lethal means and suicide. Chapter 35. The International Handbook of Suicide Prevention, 2nd Edition. Edited by Rory C. O’Connor and Jane Pirkis. Published 2016 by John Wiley & Sons, Ltd.. Baffins Lane, Chichester, West Sussex PO19 1UD, England.

I’m not sure that the argument they make when evoking reviews of the effect of legislation advances their argument. The authors should review those paragraphs and ask themselves what if anything does this text support of relevance to their important but modest point.

This Discussion and its 3 associated references regarding legislative advances have been deleted.

Attachment

Submitted filename: Reviewers Replies.docx

pone.0290138.s008.docx (19.8KB, docx)

Decision Letter 1

Claudio Alberto Dávila-Cervantes

20 Dec 2023

Fallacy of Attributing the U.S. Firearm Mortality Epidemic to Mental Health

PONE-D-23-22215R1

Dear Dr. Bleyer,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Claudio Alberto Dávila-Cervantes, Ph.D.

Academic Editor

PLOS ONE

NOTE FROM EDITORIAL STAFF: In a previous round of review, one or more of the reviewers has recommended that you cite specific previously published works, and these citations have now been incorporated into the manuscript. As always, we recommend that you please review and evaluate the requested works to determine whether they are relevant and should be cited. It is not a requirement to cite these works and removing these articles will not affect this acceptance decision. We appreciate your attention to this request.

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Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: The authors have addressed all my concerns. This is a well written, well conceived and much needed paper.

**********

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

**********

Associated Data

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    pone.0290138.s002.pdf (887.9KB, pdf)
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    pone.0290138.s008.docx (19.8KB, docx)

    Data Availability Statement

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