Two out of three people killed by guns in the United States are those who pull the trigger, with suicides outnumbering victims of firearm homicides by 2 to 1.
Of nearly 31,000 gun-related deaths in both 2010 and 2011, nearly 20,000 were suicides, compared with about 11,000 murder victims, according to the federal Centers for Disease Control and Prevention.
Given these and other grim statistics, Sonoma County Supervisor Shirlee Zane said she is appalled by the virtual silence on suicide in the national debate over gun violence.
"Nobody's talking about it," Zane said, noting that statistically, two to three Americans would have taken their own lives during a lengthy interview in her office. "It's inexcusable."
The nation's 20,000 annual gun suicides average 55 deaths -- or two Sandy Hook school tragedies -- per day.
Headlines abound when a flu epidemic erupts, taking 3,000 to 49,000 lives a year, Zane said. But the nation's rising suicide rate -- at its highest level in 15 years and accounting for the nation's 10th leading cause of death -- gets scant attention.
"It's frightening in that sense," said Zane, for whom suicide became a personal and painful matter two years ago, turning her into a public advocate for suicide prevention.
Her late husband, Peter Kingston, who was battling depression, asked a friend to remove three hunting guns from the pool house, hoping to avoid harm to himself or anyone else. About a month later, in January 2011, Kingston hanged himself. The recollection still brings tears to Zane's eyes.
In households with loaded firearms, the risk of suicide is nine times higher than in homes without weapons, a New England Journal of Medicine report said in 1992.
"People who own firearms should carefully weigh their reasons for keeping a gun in the home against the possibility that it may someday be used in a suicide," the study's authors concluded.
Mike Kennedy, Sonoma County director of behavioral health, said professionals in his field are well aware of the connection between household guns and suicide.
"The gun is there. It's available," he said. "And it is lethal."
Firearms are used twice as often in suicides (47 percent) as both of the other common methods -- suffocation (23 percent) and poisoning (21 percent) -- among people age 25 to 64, according to federal figures.
Men have a suicide fatality rate five times higher than women (15 percent versus 3 percent), largely because they use firearms half the time or more, depending on their age, whereas women of all ages primarily use suffocation and poisoning.
"The question is," Zane said, "why aren't we doing something about it?"
Banning guns is not the answer, but if people are required to get a license to catch fish, why not for buying a gun, as well, Zane said.
Programs such as Sonoma County's campaign to train teachers, students and parents to recognize the signs of potential suicide and act accordingly also are promising, Zane and Kennedy said.
Mental health outreach needs to focus on people age 16 to 25, the age when youths often experience their first "psychotic break," Kennedy said.
Adam Lanza, killer of 27 people in Newtown, Conn., last month, was 20. James E. Holmes, who fatally shot 12 people at an Aurora, Colo., movie theater in July, is 25.